Stela Bivol: „In public health, one wrong decision can kill hundreds and thousands of people. The responsibility is huge. Lets not forget that there are people behind these decisions”
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17 iulie, 2017, 10:47
Vizualizări: 2710
Moldova was dealing with widespread HIV epidemics before the Global Fund came in the country. People affected by the virus and the AIDS were dying without any second chance to life. With external finance granted to control and prevent the disease, the country has stabilised the situation, which is still sound.
Author: Elena Cioina
Moldova was dealing with widespread HIV epidemics before the Global Fund came in the country. People affected by the virus and the AIDS were dying without any second chance to life. With external finance granted to control and prevent the disease, the country has stabilised the situation, which is still sound. The Non-Governmental Organisations played a very important role through the entire process. They engaged hundreds of people under the mission to provide the persons from the risk group with social and medical services to turn their life around. The HIV-positive is not a label anymore, but a chronic disease. Because of the efforts made, those who have benefited from the services developed in the mid 2000’s can enjoy life. What are the risks if the civil society that has developed financial management skills and development of HIV/AIDS prevention is removed from this process, and their responsibilities are taken over by institutions that have never done this before? We discuss this topic with Ms. Stela Bivol, the newly appointed Director of Health Policies and Studies Centre (Centre PAS).
Ms. Bivol, you have inherited a rather unpleasant situation in matters dealt with by Centre PAS for more than 15 years. Would you like to tell us in more details, what is really going on?
I have become the Director of Centre PAS a couple of weeks ago and I do not want to go deep about the Global Fund grant-making documentation process, which lasted until the 29th of June. I would rather refer to the general context and what happened after the 3rd of July 2017.
The HIV epidemics came to Moldova in the mid 1990’s, when the injectable drug use practically exploded mainly because of the socio-economic crisis and the Soviet Union collapse, which led to an abnormal increase of HIV cases. The projects on harm reduction for these persons started in 2000 and were funded by Soros-Foundation Moldova (SFM). In 2000-2002 I was the first UNAIDS and Soros-Foundation Harm Reduction Project Coordinator in Moldova. Therefore, the prevention work for persons from the risk group is very close to my heart and I know very well the feeling of working with people affected by HIV and with high risk of HIV infection.
Does it mean you got to know young people who were using drugs and had HIV…
That is correct. I also remember extraordinary people who worked with us as our peers, but who are not with us anymore. Unfortunately, many died at a young age due to drug addiction and AIDS. What I saw and felt then, has marked me for life. Before 2003, the HIV diagnosis was a life sentence. But once the Global Fond to fight HIV/AIDS, TB and Malaria became a partner of Moldova and offered grants to control the epidemics, we have succeed to save hundreds and thousands of young people and adults. They would have had the same fate as the young people I mentioned above, if Moldova did not receive this financial support from the international organisation.
Who were developing and implementing the Global Fund projects?
The specialists of the AIDS Centre were the first to implement the National HIV Programme. They were open; they had progressive views and accepted the civil society as an equal partner in HIV control and mitigation in Moldova. The Non-Governmental Organisations are those who developed social and prevention services for people using injectable drugs and people who were already HIV-positive. In 2003, when the first Global Fund grant was offered, the health system succeeded to implement the antiretroviral treatment with the assistance of the public system. This brought hope and once the treatment became available, HIV/AIDS became a chronic disease, like diabetes. Moreover, with joint efforts and prevention projects, we succeeded to prevent the infection of hundreds and thousands of people in the country. We can see that the HIV epidemic has been stable in the past years, i.e. it does not grow or grows just insignificantly.
Today, the work of my organisation is highly appreciated in the Global Fund appraisals. Of course, the merits are shared with tens and hundreds of dedicated workers, who work in the field, and relevant Non-Governmental Organisations. But when these projects are missing and the country does not understand their meaning, the outcome is inevitable. Let’s take, for instance, Romania and Russia. They become ineligible for financing because their economy is rated good and they ranked as countries with revenues above average. The governments did not commit to overtake these projects after the completion of Global Fund grants, and consequently, the number of new HIV cases among the key population has exploded and the epidemic is taking proportions.
Moldova has to commit to finance some harm reduction projects in 2018 already. And even if we are aware that the Global Fund has reduced substantially the financing for HIV/AIDS control, the relevant authorities do not seem to undertake safe and well-structured steps in this field…
Yes, the Republic of Moldova is one of the countries that committed to gradually overtake the HIV testing, treatment and services that are currently provided by the Non-Governmental Organisations. It does better at antiretroviral treatment but it has not been able to achieve its promise – to initiate the prevention services by contracting the organisations by National Health Insurance Company (NHIC)) and the psycho-social support organisations by regional centres subordinated to the Ministry of Labour, Social Protection and Family. The transition deadline is unknown. The civil society has been lobbying for four years, assisted in developing the framework, but the State does very little. At least we know that in the next three years we will work in the same strategic directions, with the same implementation arrangements; however, with less money but more service targets than in previous period, because the number of estimated key population and of persons in need of treatment has increased significantly.
Since we are not officially a country in transition, it means that we have three more years of financing, so we are talking about six-year horizon. At least, this is the idea expressed in the country grant continuation proposal for the next three years sent for appraisal to the Global Fund. However, after the Global Fund approved these intentions, the detailed document development process was turbulent during the last weeks because the budget is smaller and the targets are higher and because the team of the National HIV/AIDS Control Programme Coordination Council is less willing to be a partner to those who have been working in the field for more than 15 years. It [NCC] comes with authoritarian and even dictatorial approaches, according to one of our long-time partner.
What has changed since the 29th June, when the last meeting of the National Coordination Council for TB/HIV took place?
The process, so familiar since 2003, took a nasty turn on the 29th of June in the NCC meeting, when for the first time, new options were presented without prior discussion in the technical Working Group responsible for grant application development and which culminated with the voting of changing the arrangements applied for the grant. The amendments were voted by 10 out of 28 votes, hence, an insufficient number of votes to be considered compliant with the NCC Regulation, which stipulates 2/3 of votes to approve the resolution or, moreover, to reach a mutual agreement, according to NCC Operational Manual.
We have signalled in detail a number of infringements of minimal requirements of the NCC activity and its Regulation and procedures during the meeting, and we are waiting for the conclusions of relevant national and international institutions on these.
More than that, this hasty decision resulted in different opinions of governmental (+1 non-governmental), international actors, which traditionally abstain from diplomatic reasons but have backstage opinions, and non-governmental actors. So far, there is no solution to the differences of opinions.
What happened next?
On July 4, six members of NCC appealed officially the decision on the agenda item 2; however, neither the NCC Chairperson nor the Secretariat has come up with an official or unofficial answer. Moreover, the set of documents developed exclusively by the Coordination Unit of the NP HIV, UCIMP and the only appointed sub-recipient NGO Positive Initiative was submitted to the Global Fund on July 7. Soros Foundation Moldova has withdrawn itself as sub-recipient, which according to its institutional policy cannot be contracted by a state agency.
The technical reason provided during the decision-making was the necessity to streamline the transfer of the programmes to the State and the transfer of programmes to one Principal Recipient with one sub-recipient is the much-desired transfer mechanism. Personally, I have difficulties to understand it.
What risks do you envisage, if all HIV/AIDS Control and Prevention Programmes are overtaken by one sub-Recipient of the Global Fund, and namely the Government?
First of all, the Global Fund asked for the transfer to be done to the state institutions that would cover these services. But neither the Health Project Coordination, Implementation and Monitoring Unit (UCIMP), nor the Hospital for Dermatological and Communicable Diseases (SDMC) nor the Non-Governmental Organisation Positive Initiative are structures that would manage the HIV situation nationwide in three years from now. Why? Because the UCIMP is 100% dependent on the Global Fund financing and has no role of implementing party which can receive the activities according to the transition plan. In the context of hospital reform and state sanitary service reform, it is not clear how the HIV Program Coordination Unit of the SDMC will be reorganised and who will coordinate the national programmes in 2-3 years. As for the NGO Positive Initiative – its role is also unclear – service provider or grant manager? The best option is to transfer to the CNAM. The new streamlined implementation formula does not explain any of these; it is clear that the terms are being changed knowingly.
How should this transition unfold?
According to discussions we had in many meetings and Working Groups, the capacity transfer should be directed to National Health Insurance Company (NHIC) and Ministry of Social Protection or future Ministry and not to other temporary entities that at this moment, do not even have experienced specialists in prevention or grant management skills. Why was not this thing discussed in the NCC meeting and why the attempt to solve this issue was stopped immediately? This is a question.
So a number of questions are still unanswered?
Our questions with regard to the procedure based on which only one Principal Recipient was selected have not been answered by the NCC representatives, saying just that the Recipients were already confirmed once the initial application was submitted. That’s a good one.
Why only two ideas are considered – one that Centre PAS did not want to decrease the administrative costs and two: that we do not care about the beneficiaries? Because it sounds good for the public, it can be speculated and nobody would understand anyhow whether we, as an institution, were fair, coherent and provided justification, whether we want to continue the programmes we have started years ago and even if we want to transfer them to the State or just to discuss who cares more.
Who can prove who cares more? Those who have been involved daily since 2000 or new implementers who not so long ago were government officials and announced solemnly that would take care of the prevention services, and now in meetings say that the State would never assume these programmes and that their effects still have to be proved? Or those who do not believe in substitution therapy and change of syringes for the injectable drug users, but for the public ears say that they care and can do anything?
Another non-argument discussed by the Government representatives in the NCC was that we are those who endanger the continuation of HIV/AIDS control services by delaying the grant making process. I am 100% sure that the Global Fund has sufficient instruments to ensure the continuation of services and has done it before a few times, including in Moldova. What is really a high risk that can affect the continuation of services and future results and impact on human lives is when those in project management are removed to bring those focused on advocacy and procurements to manage the grant and who promise to implement everything with very small costs. These are only words and empty promises, with no proof, or capacities. They have not been even appraised by the Global Fund.
How will happen in the end?
Sooner or later, a decision will be made. A political or technical - we will see. I remember what my Public Health Professor from Boston told me once – in medicine, the Doctor knows who is saved and who is kills, the outcome is seen immediately. In public health and prevention, the decisions are indirect, but have greater impact. One wrong decision can kill hundreds and thousands of people, hence, the huge responsibility. We should not forget that there are people behind every decision. I wish everyone would support his or her decisions on these wise words.
Ms. Bivol, thank you for this interview.
Categoria: Interviuri
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