In Middle of the Middle East

30 August 2016

I realize now that I really needed to visit Beirut to make an attempt to understand how things are going in sustaining harm reduction programs in the Middle East and North Africa. It became a great opportunity to meet and talk to dozens of people from Lebanon, Jordan, Egypt, Morocco, and Pakistan. Technical assistance is a two-way process: you can make no progress without helping others.

MENAHRA, a harm reduction network working in the Middle East and North Africa (MENA), wanted our assistance in finalizing several components of their regional project submitted to the Global Fund. First of all, MENAHRA needed help identifying what can be done in a two-year timeframe to promote the development of community systems with a focus on key populations, such as people who use drugs and people living with HIV. Second, it was important to work on a regional strategy for transition to domestic funding to maintain HIV programs for all key populations.

On the first visit to a country (even more so, a region), we just can’t help comparing everything with how things are done “at our place.” As it turns out, we have a lot in common with the Middle East. In general, making a small grant money transfer to Iran would be as complicated as to Uzbekistan.

Drug use is highly criminalized at both our region and MENA, which prevents people who use drugs from being meaningfully involved in the development of HIV programs and budget advocacy. In a number of MENA countries, key populations are extremely criminalized to the extent that even raising an issue of piloting programs for MSM or sex workers would be enough to place oneself in the line of fire from the governing authorities. A number of country governments in the regions just do not admit the very fact that key populations exist in the country, as a result, programs for them are totally non-existent.

Just as in our home region, a high national income level does not imply correspondingly high levels of commitment and funding of the national AIDS program. Quite the contrary: high or upper-middle gross national income per capita are an indication of the fact that the country might have never been a Global Fund recipient of funding for the development of programs for key groups, and these programs are either non-existent or run by local NGOs in a pilot mode and with a modest financial support from MENAHRA. It has its effects on the development of the strategy for transition to domestic funding. In many countries of the region, the actual goal is as follows: how to manage the transition from pilot programs, with minimum international funding levels, to the national funding with the quality and coverage in compliance with the WHO guidelines? It’s not that easy, isn’t it? Whereas, in most high and upper-middle income countries, governments only provide funding for HIV testing and first-line ART.

However, our region would do well to learn from the Middle East and North Africa countries in many aspects. In Iran, harm reduction programs have received governmental support sufficient to enable them to operate 682 needle exchange and 4,275 substitution therapy sites as of the year of 2014, with the Global Fund co-financing level not exceeding 15%.

In Lebanon, OST programs are implemented on the NGO level. A Beirut-based OST program, "Service Infirmier à Domicile" (SIDC), currently involves some 200 clients. No police, no cam footage, no security bars. The program procedure is quite simple. First, the client will be interviewed by a panel involving a nurse, social worker, and peer consultant; then he has to visit a dedicated doctor (who receives patients right here at the NGO premises). The case is then submitted to the Ministry of Health for consideration and final decision. Overall, the whole procedure takes no longer than a week. Upon approval, the client is supposed to visit SIDC once a week to get a renewable prescription (medication order) to receive their one-week supply of medications from one of the two certified hospitals in Beirut. There are two problems—only buprenorphine is available, and it is provided on a paying basis (which costs about 120 USD per month). It used to be more expensive until recently when the Ministry of Health has included buprenorphine to the list of regulated drugs which allows reducing its price by 30%. As you might guess, it became possible only after multiple complaints submitted by program clients for a long time.

As regards the prospects of receiving public funding, SIDC personnel are quite pessimistic. So far, municipal authorities provide them no more than 8,000 USD per year—for institutional development, not for harm reduction, and SIDC is a rather an exception, because many other NGOs do not get any municipal co-funding. However, I think it is not bad for a start—and certainly better than in most cities in the EECA region.

So what we, as a network, can do for SIDC and other NGOs involved in MENAHRA?

We’ve got tools for financial monitoring, and we have some experience (albeit small) in budget advocacy.

We’ve got tools for the community-driven program quality evaluation.

We build upon our experience in various countries that share common problems.

We’ve got strong PWUD networks working all across the region including countries with criminalization levels as high as in the Middle East.

We have not yet succeeded in obtaining considerable funding for harm reduction from national budgets, but we have already learned our important lessons and we know how to avoid mistakes...

And most importantly, we strongly believe that we can make a difference. When it comes to the state budget bureaucratic machine, this faith is crucial to get it moving, and this is what we can share with our colleagues in the Middle East and North Africa countries as well. “Heart to heart,” as our Max Malyshev from the Andrey Rylkov Foundation loves to say.

This technical assistance to MENAHRA has been provided by EHRN under the Global Fund CRG Special Initiative.