'It's risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan

BACKGROUND: Despite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs). METHODS: Semi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors. RESULTS: Stigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included:criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers. CONCLUSIONS: Approaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector

Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic

Aim: An assessment of the training needs and interests of health managers working in the health care facilities of the Kyrgyz Republic was conducted, aiming to tailor and shape future training interventions. Methods: A rapid assessment was organized among directors of health care services in the Kyrgyz Republic, using a web-based questionnaire. Due to the pandemic situation (COVID-19), it was impossible to involve all healthcare facilities as initially planned. Therefore, a convenient sample of 75 directors was drawn with a response rate of 77.3%, or 58 filled-in questionnaires. Results: Among respondents, 60.3% were female and 39.7% male managers, with an average age of 53.5 years. Most of the respondents (89.7%) came to a managerial position by direct appointment, while only 10.3% were appointed through competitive process. More than half of health managers (63.8%) do not have any managerial category, and only 25.7% indicated that they have membership in the Association of Health Administrators of Kyrgyzstan[1]. All respondents reported the need to develop computer skills. Discussion: There is a high demand in all aspects of the management of health organizations. The respondents are deciding about involvement in management training based on (a) the full range of training' topics, (b) the quality of the training content, and (c) the focus on developing practical skills. The most cited training needs are digital health (E-Health), financing management, planning, and quality control; the interest in distance learning courses is excellent. Almost two-thirds of managers reported that the Ministry of Health and Social Development (MOHSD KR) did not evaluate their work. Conclusion: The main implications derived from this assessment are related to the culture of lifelong learning among the population of Kyrgyz health managers.   Authors’ contributions: All authors contributed equally.   Conflict of interest: None declared.   Source of funding: The project is financed by the Government of Switzerland. The opinions expressed in this publication are the views of the authors and do not necessarily reflect the opinion of the Government of Switzerland

Assessment of the training needs and interests among directors of health care services in the Kyrgyz Republic

Aim: An assessment of the training needs and interests of health managers working in the health care facilities of the Kyrgyz Republic was conducted, aiming to tailor and shape future training interventions. Methods: A rapid assessment was organized among directors of health care services in the Kyrgyz Republic, using a web-based questionnaire. Due to the pandemic situation (COVID-19), it was impossible to involve all healthcare facilities as initially planned. Therefore, a convenient sample of 75 directors was drawn with a response rate of 77.3%, or 58 filled-in questionnaires. Results: Among respondents, 60.3% were female and 39.7% male managers, with an average age of 53.5 years. Most of the respondents (89.7%) came to a managerial position by direct appointment, while only 10.3% were appointed through competitive process. More than half of health managers (63.8%) do not have any managerial category, and only 25.7% indicated that they have membership in the Association of Health Administrators of Kyrgyzstan[1]. All respondents reported the need to develop computer skills. Discussion: There is a high demand in all aspects of the management of health organizations. The respondents are deciding about involvement in management training based on (a) the full range of training' topics, (b) the quality of the training content, and (c) the focus on developing practical skills. The most cited training needs are digital health (E-Health), financing management, planning, and quality control; the interest in distance learning courses is excellent. Almost two-thirds of managers reported that the Ministry of Health and Social Development (MOHSD KR) did not evaluate their work. Conclusion: The main implications derived from this assessment are related to the culture of lifelong learning among the population of Kyrgyz health managers

Tracking Global HIV/AIDS Initiatives and their Impact on the Health System: the experience of the Kyrgyz Republic

This report presents results from a desk-based review and fieldwork conducted between April 2008 and January 2009 in three regions of Kyrgyzstan - Bishkek/Chui, Osh/Jalalabad and Issyk-Kul. The aim of the report is to assess the effects of two global health initiatives (GHIs) for HIV/AIDS the Global Fund to Fight AIDS, TB, and Malaria (GFATM) and the World Bank\u27s Central Asian AIDS Project (CAAP) at national and sub-national levels, including the effects on HIV/AIDS service scale-up coordination, human resources, and access to HIV/AIDS services

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations

National and subnational HIV/AIDS coordination: are global health initiatives closing the gap between intent and practice?

BACKGROUND: A coordinated response to HIV/AIDS remains one of the 'grand challenges' facing policymakers today. Global health initiatives (GHIs) have the potential both to facilitate and exacerbate coordination at the national and subnational level. Evidence of the effects of GHIs on coordination is beginning to emerge but has hitherto been limited to single-country studies and broad-brush reviews. To date, no study has provided a focused synthesis of the effects of GHIs on national and subnational health systems across multiple countries. To address this deficit, we review primary data from seven country studies on the effects of three GHIs on coordination of HIV/AIDS programmes: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank's HIV/AIDS programmes including the Multi-country AIDS Programme (MAP). METHODS: In-depth interviews were conducted at national and subnational levels (179 and 218 respectively) in seven countries in Europe, Asia, Africa and South America, between 2006 and 2008. Studies explored the development and functioning of national and subnational HIV coordination structures, and the extent to which coordination efforts around HIV/AIDS are aligned with and strengthen country health systems. RESULTS: Positive effects of GHIs included the creation of opportunities for multisectoral participation, greater political commitment and increased transparency among most partners. However, the quality of participation was often limited, and some GHIs bypassed coordination mechanisms, especially at the subnational level, weakening their effectiveness. CONCLUSIONS: The paper identifies residual national and subnational obstacles to effective coordination and optimal use of funds by focal GHIs, which these GHIs, other donors and country partners need to collectively address

Rights and responsibilities: Women leadership for health in Kyrgyzstan.

The World Health Organization (WHO) is committed to empowering countries by implementing a gender, equity, and human rights approach in the health sector. The objective of this gender and inclusion analysis is to assess potential gender disparities of health sector management in the Kyrgyz Republic. The employed mixed-method approach takes advantage of data triangulation. Besides information from the literature and policy documents available at the international and national levels, the analysis includes interviews and data from the self-assessment of health services managers in the Kyrgyz Republic. A convenience sample of 75 health managers was taken and after up to three reminders a commendable response rate of 80% was achieved which resulted the final sample size of N = 60. A factor analysis using quartimax orthogonal rotation was applied to investigate the correlation between Teaching Qualification, Digitalization, Training Usefulness, Computer Workplace, and Gender Equality. In 2021, the Kyrgyz Republic adopted a new Constitution, which provides a sound legal framework to support gender equality and promote women's empowerment. However, according to a survey, only 42.9% of the respondents felt that equal rights and opportunities were integrated into their job descriptions. Similarly, only 40.7% believed that their institutions' written documents reflected a commitment to equal rights and opportunities for both genders. Two factors were identified as influencing gender equality: (1) personal and (2) technical aspects. Regarding personal aspects, gender equality, teaching qualification, and training usefulness were found to be significant. Regarding technical aspects, the computer workplace was related. In recent years, the Kyrgyz Republic has been developing a culture of gender equality. Political will is essential to promote and make organizational change possible. It is important to create a written mid-term policy that affirms a commitment to gender equality in organizational behavior, structures, staff, and management board compositions. Healthcare institutions need to prepare strategic and operational plans that incorporate gender equality principles

Circus monkeys or change agents? Civil society advocacy for HIV/AIDS in adverse policy environments.

This paper explores the factors enabling and undermining civil society efforts to advocate for policy reforms relating to HIV/AIDS and illicit drugs in three countries in Eastern Europe and Central Asia: Georgia, Kyrgyzstan and Ukraine. It examines how political contexts and civil society actors' strengths and weaknesses inhibit or enable advocacy for policy change - issues that are not well understood in relation to specific policy areas such as HIV/AIDS, or particular regions of the world where national policies are believed to be major drivers of the HIV/AIDS epidemic. The study is based on in-depth interviews with representatives of civil society organizations (CSOs) (n = 49) and national level informants including government and development partners (n = 22). Our policy analysis identified a culture of fear derived from concerns for personal safety but also risk of losing donor largesse. Relations between CSOs and government were often acrimonious rather than synergistic, and while we found some evidence of CSO collective action, competition for external funding - in particular for HIV/AIDS grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria was often divisive. Development partners and government tend to construct CSOs as service providers rather than advocates. While some advocacy was tolerated by governments, CSO participation in the policy process was, ultimately, perceived to be tokenistic. This was because there are financial interests in maintaining prohibitionist legislation: efforts to change punitive laws directed at the behaviors of minority groups such as injecting drug users have had limited impact

An assessment of interactions between global health initiatives and country health systems

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity value for money, and outcomes in global public health, then these opportunities should not be missed