Claire Fahlman

March 6, 2016
Global Fund Assignment Seven
1. Provide a brief introduction to your overall plan and strategy for the proposal.
The political climate of Ukraine is currently very volatile and unstable. In the eastern portion of the
nation, particularly the Crimean region, a Russian-backed separatist insurgency is attempting to secede
from Ukraine and potentially rejoin Russia, in part due to leftover animosity after the fall of the Soviet
Union. After an uprising in 2014, the corrupt ex-president, Viktor Yanukovych, fled to Russia. The new
president, Petro Poroshenko, is so far more popular and has not yet been caught in any corruption
scandals. As far as commitment to health services goes, Ukraine has not shown a huge amount of
dedication. The nation has the lowest health expenditure per capita in Europe, as well as the fastest-rising
HIV+ population in Europe. Although the low health expenditure per capita is in part due to a lack of
funding, it is also at least partially due to a misallocation of resources.
Ukraine is the subject of a Structural Adjustment Program (SAP) from the International Monetary Fund
(IMF). The economic situation has been dire since the very beginning of the European debt crisis in 2008.
The SAP initially was supposed to help Ukraine gain a better financial footing but instead has added to its
inability to provide adequate health services to its citizens. Under a new self-driven SAP, otherwise
known as a Multilateral Debt Relief Initiative (MDRI), Ukraine has unveiled a new set of debt and economic
policies. These were not exactly self-driven, as one may be led to believe from the name, but instead
were conditions that were required to be met by the IMF in order for Ukraine to receive additional
economic relief. This economic relief will most likely not go towards health care but rather towards either
paying off other debts or fighting the separatist insurgency in the East.
One of the goals outlined in this proposal is to train more health practitioners. There are fewer doctors
per 100,000 people in Ukraine than anywhere else in Europe. This is due to a combination of factors,
specifically the conflict in Eastern Ukraine. As a politically unstable nation with economic troubles, Ukraine
is not particularly supportive of its doctors and nurses and the Ministry of Health doesnt fund its hospitals
particularly well, either. Many doctors have left because they are paid better in other countries and are
more supported. The other half of the issue is the cost of health training. Schooling for doctors or nurses is

very expensive. By subsidizing schooling for health practitioners by 10%, the goal is to see a 10% increase
in health practitioners in the country.
Another goal is to increase the proportion of the HIV+ population receiving ARV therapy. Fewer than
two-thirds of those eligible for treatment are enrolled in generalized HIV care, let alone ARV therapy. A goal
set by the WHO was to reach 80 percent of the eligible population by 2013. They fell short of this goal for
many reasons, one of which was confusion among different lines of treatment. By one report, there were
38 different regiments of first-line care recommended in AIDS care centers, few of which were actually
available when prescribed. By increasing the sales of generic ART drugs, such as those produced in India,
access to ARV therapy could be increased and more of the eligible population could be met.
As much as 60% of the HIV+ population in Ukraine uses intravenous drugs. This is why one goal is to
open safe injection sites, or places where drug addicts can shoot up with clean equipment and avoid
infecting themselves or others. Though it is true that not being dependent on drugs is better than being a
user, and being drug-free is less likely to spread HIV than using drugs, an intermediate step may be
needed. By providing addicts with a safe space to use drugs, they can also be met with information on HIV
prevention and treatment for addiction.
Along the same educational lines, increasing HIV and health education in schools can help prevent
further infections. With no HIV education, it is almost impossible to prevent infections, as people dont
know how to prevent themselves from a disease they have no information on. Classrooms are the ideal
place to reach young people with HIV education, as they have to be in school and, for the most part, are
likely not yet taking part in the high-risk behaviors that can lead to HIV infection. By giving students the
tools to protect themselves against HIV, the goal is to create a generation that is much better able to
protect itself.
2. Revisit and revise the goals you set initially in assignment #3 (it is completely acceptable to modify
your previous goals and plan based on what youve learned in the intervening weeks). If youve
made changes, explain and justify those changes.
Claire
Fahlman

Goal-setting table for Global Fund program

In Ukraine targeting HIV/AIDS

STAFF
WHAT?

Indicator

More health
practitioners

STUFF
Increase proportion of
HIV+ receiving ARV
therapy

Payroll increase by 10% ARV provisions up by 30%

SPACE
Safe injection sites

Permits granted for safe

injection sites up by 10%

SYSTEMS
Education towards HIV
prevention

Decrease in HIV infectio

25%

HOW?

Increase financial
Increase availability of
support for those
generic brands by 30%
studying health by 10%

Number of safe injection

sites applied for increased by Health education in 25%
10%

Indicator

Student debt decrease

by 10%

Public records of site

applications increased by
10%

Generic ARV brand sales

increase by 30%

Proportion of schools wit

education up by 25%

3. Write a brief narrative that describes what you aim to accomplish in each goal category (staff, stuff,
space, and systems). Remember, your work should be guided by big ambitions (e.g. extend
coverage of ARV therapy to 90% of HIV positive people in all regions of X country, improve national
case-finding for TB), or inputs, such as to build 30 new health clinics in X cities. Explain why you
have chosen to design the intervention you have, what you hope to accomplish, and why you think
this is what the country needs right now.
Staff
One of the largest overall gaps in the healthcare system of Ukraine is the lack of both nurses and
doctors. Ukraine has less than the average European amount of doctors and nurses in the workforce, which
means less people that are available to provide healthcare. The way to measure an increase in health
practitioners would be by a payroll increase of at least 10%, indicating that there are more paid health

professionals in the country. In order to have more doctors and nurses, Ukraine needs to train more of
both. The cost of a medical education can be a large deterrent, especially in lower-middle income countries
such as Ukraine. With more government financial support and incentives, more Ukrainian students would
be able to train to become health professionals. The effectiveness of this strategy would be measured by a
10% decrease in medical student and nursing student debt after graduation.
Stuff
In order to better address the HIV epidemic in Ukraine, the percentage of the population of HIV+
individuals who need ARV therapy needs to be increased. This could be indicated by a 30% increase in the
population of HIV+ individuals who need ARV therapy and are receiving it. There are many different factors
that come into play regarding the distribution of ARV therapy, but perhaps the most influential is cost.
Brand name ARV therapy is expensive, but generic brand ARV therapy is much cheaper. This would allow
the poor, the population most affected by HIV/AIDS, better access to the life-saving therapy they need. An
increase in the availability of generic brand ARV therapy would be indicated by a 30% increase in generic
brand ARV therapy prescriptions.
Space
The growing HIV epidemic in Ukraine is largely facilitated by a surge in IV drug use. Because of unsafe
and unclean needles and a culture of sharing drug paraphernalia, HIV is spreading rapidly through the IV
drug-using population. By opening clean, legal safe injection sites for addicts to shoot up in with access to
clean needles, the spread of HIV could be slowed among this vulnerable population. This could be
measured by an increase in permits for these safe injection sites. The how part of this question is more
difficult, as it calls into question stigmatization and cultural norms surrounding drug abuse. However,
through advocacy work regarding HIV awareness and a legal push for these safe injection sites, the idea of
a safe space could become a reality. This would be measured through bills passed legalizing safe injection
sites.
Systems
The push towards the prevention of HIV/AIDS in Ukraine could be improved. There are simple ways to
keep oneself safe from HIV/AIDS (use clean needles, use a condom, know your HIV status), and by

promoting these steps, less people would be infected. Success in this initiative would be indicated by a
decrease in the annual HIV infection rate by 25%. One way to promote prevention would be by expanding
health education in secondary education. Although some schools may already have HIV education, by
expanding these programs to all secondary schools, many lives could be positively impacted. An expansion
of this system would be measured by an increase in the percent of schools with HIV education by 25%.
4. Describe how the goals and objectives add to or complement activities already undertaken by the
government, external donors, the private sector or other relevant partners (e.g., do they build on or
scaleup existing programs; do the goals and impacts aim to fill existing gaps in national programs;
does the proposal fit within the National Plan; is there a clear link between the goal(s) and broader
development policies and programs such as Poverty Reduction Strategies or SectorWide
Approaches, etc.).
My first goal, increasing the number of health practitioners in Ukraine, works in tandem with a push by
the Ukrainian government to prevent and stop corruption. Corruption is an unfortunate reality among
many layers of Ukrainian society, including doctors. Funding for hospitals and clinics is minimal, even
before any money is siphoned off by corrupt bureaucrats. This lack of funding can be depressing for
current doctors and a deterrent keeping prospective health practitioners from beginning training. By
cutting down on corruption and pushing to expose the corrupt members of the government, more money
will become available for hospitals and clinics and health careers will become more attractive to potential
doctors and nurses.
The Ukrainian Ministry of Health is also partnered with many other agencies to increase the
accessibility of ARV therapy. The Global Fund is already involved with expanding the coverage of ARV
drugs. Not every clinic is receiving the drugs they need, however. At a Kiev HIV clinic, only 26% of HIV+
people were able to receive the recommended ARV therapy. In Zhitomir, only 17% were able to receive
their medication. This extra grant would allow the coverage to be expanded to cover even more of the
people who need it.
Safe injection sites work in partnership with a push by the Ministry of Health to expand access to opioid
replacement drugs for those who inject drugs. Although the government has used opioid replacement
therapy as a tool for political advancement, it has remained committed to increasing access. The push for
safe injection centers is another part of the same theme: expanding treatment and combatting HIV

infection among the injection-drug using population. Opioid replacement therapy could even be offered at
the safe injection sites as an alternative form of treatment, joining the two approaches into one.
UNICEF, the WHO and other organizations are already involved in health education in Ukraine. By
expanding on their work and potentially partnering with them, this grant could provide an opportunity to
create universal HIV education. By implementing HIV education, a generation of Ukrainians would be
armed with the knowledge of how to protect themselves from HIV infection. With no information, it is
impossible to be protected from the disease.
5. Describe how the goal(s) address the following issues (1 paragraph per item):

Involvement of beneficiaries such as people living with HIV/AIDS

Community participation

Gender equality issues

Social equality issues

Human resources development

Harm reduction centers provide an opportunity to involve beneficiaries in their treatment by offering an
outreach opportunity. They would allow addicts to take control of an aspect of their condition, empowering
them to make other health decisions. The harm reduction centers would also provide an arena for further
HIV education. By providing addicts with information on their elevated risk for HIV infection while giving
them a safe space, the risk of infection in the future is also decreased. Those helped by the centers would
be able to spread information, both about the harm reduction centers and treatment options, to their
peers, thus involving them in the fight to prevent infection. Spreading the coverage of ARV therapy is also
an opportunity to involve beneficiaries. Those receiving ARV treatment would have their health improved,
thus giving them the opportunity to lead longer, more meaningful lives, with which they could spread
information about ARV treatment to other members of the HIV+ population. Through education, they

would be given a better sense of how they became sick and how they could prevent others from becoming
sick as well, which is an important part of the fight against HIV.
The educational goal is an excellent opportunity to foster community participation. The health of
children is something that entire communities can agree upon the importance of. By placing an emphasis
on the wellbeing of young people, parents and family members are more likely to become involved. The
information that children learn by this educational initiative could be taken back to their families and
spread, thus protecting the health of the entire family. Those affected by HIV could speak to classes, thus
involving another community in the fight against HIV transmission.
The educational goal also provides an opportunity to address gender equality issues. By separating
girls and boys for education, girls can be particularly targeted with specific information and empowering
messages that allow them to make the choices that would keep them HIV free. Gender specific messages
would include information on the use of condoms and how no one should be able to force a woman to have
unprotected sex. Although it may seem obvious, the message of being worth using a condom for is
empowering and not as obvious as one would think. This would allow young women to take ownership of
their status and protect it.
The biggest social inequality in Ukraine is between the rich and the poor. The only way to lessen this
divide is to provide educational opportunities. The goal to subsidize health provider education would help
to reduce the divide between the wealthy and the general population by providing a method of upward
mobility. Access to medical and nursing schools is largely dependent on the cost of education, so by
lowering this cost, more people would be able to afford this opportunity for mobility.
Human resources would also be developed by the subsidization of health worker education. The lack of
health professionals in Ukraine could be lessened by opening up access to a wider group of people. By
treating the education of doctors and nurses as a priority, the new doctors and nurses would feel more
empowered and as if they are more appreciated in Ukraine as well, which could potentially lessen brain
drain and allow more health providers to remain in the country. With more health providers comes better
HIV care, which could also lead to better prevention of HIV transmission.

6. Discuss potential opposition (donors, other stakeholders) to the plan. How will you address it?
The most likely form of opposition would be from the corruption within the Ukrainian government
itself. Rather than the usual way that NGOs interfere with the local Ministry of Health, in Ukraine, it is
nearly the opposite. The Ministry of Health has a history of corrupt and uneven funding allocation to clinics
around the nation. This inability to allocate funds properly interferes with NGOs donating to the Ministry of
Health and their ability to accomplish their goals. As in the case of the clinic in Zhitomir, where 18 doctors
were on the payroll but only two actively practiced the specialty of the clinic, infectious disease, there are
many incidences of improper allocation of funds in the Ukraine. In the case of the Global Fund, the Ministry
of Health misallocated Global Fund donations and some of them may have been embezzled by employees.
The Global Fund recently released an entire report analyzing what it did wrong, although the only mistake
on the part of the Global Fund may have been funding a dysfunctional system. Because of this flawed
system, many NGOs choose to work around the Ministry of Health rather than along side of it. In many
cases, it is faster, easier and more cost effective to provide ARV therapy and HIV testing independent of
the Ministry of Health.
This can only be addressed with transparency and a watchful eye. As with the Global Funds previous
interventions, the release of funding decisions and information regarding the allocation of funds would be
published online. Any Global Fund donations would have to be published and only given to the Ministry of
Health if it promises to account for the whereabouts of every dollar. If that condition is met, then there
should be no problem with corruption.

7. Include your map (or maps) as a figure with a proper title.

The Geography of HIV in Ukraine

Works Cited

Bullough, Oliver. "Welcome to Ukraine, the Most Corrupt Nation in Europe." The Guardian. Guardian News and
Media, 06 Feb. 2015. Web. 06 Mar. 2016.
"HIV/AIDS Treatment and Care in Ukraine." WHO (2013): n. pag. WHO, 2013. Web. 6 Mar. 2016.
Khmara, Oleksii. "Anti-corruption Reform in Ukraine: Going round in Circles." Space for Transparency. N.p., 16
Nov. 2015. Web. 06 Mar. 2016.
Vickery, Matthew, and Sheren Khalel. "In Eastern Ukraine, Doctors Are Terrorists and Antibiotics Are Herbs." FP
Dispatch. FP, 4 May 2015. Web. 06 Mar. 2016.