All four countries have made improvements to increase OAT sustainability. In 2022, Ukraine had a substantial degree of sustainability, followed by Belarus and Moldova with a moderate degree, while Tajikistan’s sustainability was at moderate-to-high risk. No country received the highest value (high degree of sustainability) or received the lowest value in the sustainability measurement scale (at high risk of sustainability) in any of the dimensions and indicators.
Table 2: OAT sustainability across the three dimensions measured in the four countries in 2020 & 2022-2023.
Sustainability dimension
|
A. Policy & Governance
|
B. Finance & Resources
|
C. Services
|
Years
|
2020
|
2022/23
|
2020
|
2022/23
|
2020
|
2022/23
|
Belarus
|
Moderate
|
Moderate
|
Moderate
|
Substantial
|
At moderate-to-high risk
|
Moderate
|
Moldova
|
Moderate
|
Moderate
|
Substantial
|
Substantial
|
Moderate
|
Moderate
|
Tajikistan
|
At moderate-to-high risk
|
At moderate-to-high risk
|
At moderate-to-high risk
|
At moderate-to-high risk
|
At moderate-to-high risk
|
At moderate-to-high risk
|
Ukraine
|
Moderate
|
Substantial
|
Moderate
|
Moderate
|
Moderate
|
Substantial
|
Across the three dimensions, there is a great diversity among the countries, as shown in Table 2. In 2022, Belarus and Moldova achieved the highest scoring of substantial sustainability in the dimension of ‘Finance & Resources’, while Ukraine was rated best, with a substantial degree of sustainability for ‘Policy & Governance’ and ‘Services’.
In terms of the changes in sustainability between 2020-2022, overall scoring remained at similar levels in Moldova and Tajikistan, while in Belarus, and particularly in Ukraine, sustainability improved. In 2020, Moldova received the highest scores on OAT sustainability, followed by Belarus and Ukraine. Tajikistan was assessed as having OAT at moderate-to-high risk across all dimensions in both years. In the case of Ukraine, the degree of sustainability on the ‘Finance & Resources’ dimension was on a trajectory of improving in 2020 before the full-scale war with Russia, but the war and economic situation required the reallocation of state resources which were replaced by Global Fund support and, therefore, no improvements in this particular dimension were registered since 2020 and the end of 2022. However, the country achieved the highest progress among the four countries analysed since 2020.
Dimension of ‘Policy & Governance’
The dimension of ‘Policy & Governance’ comprises two equally weighted indicators: ‘Political commitment’ and ‘Management of transition from donor to domestic funding’.
Table 3: Scoring of indicators for ‘Policy & Governance’
Indicator
|
Political commitment
|
Management of transition from donor to domestic funding
|
Years
|
2020
|
2022
|
2020
|
2022
|
Belarus
|
Moderate
(56%)
|
Moderate
(59%)
|
Moderate
(55%)
|
Moderate
(50%)
|
Moldova
|
Moderate (65%)
|
Substantial (80%)
|
Substantial
(71%)
|
Moderate (42%)
|
Tajikistan
|
Moderate
(60%)
|
Moderate (53%)
|
At high risk
(19%)
|
At high risk (23%)
|
Ukraine
|
Moderate
(61%)
|
Substantial
(77%)
|
Moderate
(68%)
|
Substantial
(75%)
|
For the indicator of ‘Political commitment’, moderate or substantial progress is recorded in all four countries. Across the four countries in both 2020 and 2022, OAT is strongly supported by HIV-specific documents and clinical drug treatment documents, including national HIV strategic documents, and the HIV budget planning and clinical protocols on drug treatment approved by the respective Ministries of Health. However, the drug strategies and action plans, even if they explicitly mention OAT (Moldova), are not funding OAT. In Moldova and Ukraine, the ‘Political commitment’ indicator moved from moderate to a substantial degree of sustainability, in both cases showing a greater commitment to a public health approach in drug policy documents and commitments to scaling up. In Moldova, the Ministry of Justice initiated amendments to the Criminal and Administrative Codes in the provisions related to punishments for the use of narcotic substances, and the introduction of alternatives to imprisonment, while its parliament initiated a working group dedicated to the development of services for people who use drugs, and the Government adopted a new national HIV strategic plan (2021-2025) with the commitment to scale up OAT. Ukraine’s government was to adopt a draft Strategy of the State Policy towards Drugs until 2030 with a greater appreciation of a public health approach, with adopted targets for OAT scale up, while the Ministry of Health amended the main regulatory act on OAT to increase its attractiveness for clients and providers and demonstrated a proactive position to find solutions to increasing coverage of OAT despite the COVID-19 pandemic and Russia’s full-scale invasion of Ukraine that started in 2022.
In Tajikistan, while OAT has been scaled up nationally and is included in the clinical and operational guidance for drug treatment, the original ministerial act on its pilot status has not been revised. Moreover, OAT is seen more as an HIV prevention intervention as well as a less advantageous option in comparison with abstinence-focused drug treatment approaches by some officials and even NGOs. The National Drug Control Strategy of the Republic of Tajikistan for 2021-2030 does not mention OAT. At the regulatory level, legislative restrictions in Tajikistan remain, limiting the rights of all clients of state drug dependence services and requiring them to join a state registry from which personal data could be used for purposes outside health needs (such as a certificate required for employment or higher education). Similarly, in Belarus, state drug dependence services are mandated by law to share their client data with law enforcement.
Based on the analysis of the indicator of ‘Management of Transition from Donor to Domestic Funding’, all four countries are planning donor transition of their HIV programmes, while the four countries are at different stages of the transition from the Global Fund. Belarus and Moldova - being classified as upper-middle income countries - are closest to donor departure, while Tajikistan and Ukraine - as lower-middle income economies - are furthest[3]. Ukraine is the only country with an improved rating from a moderate to a substantial degree of sustainability for this indicator, mainly because of its Transition Plan, called 20-50-80, which largely reached its OAT-related objectives by the end of 2020 as the country has set up a sustainable approach for the state to fund OAT, both medications and services35. In 2022, the country had to resort to donor support for medications due to storage being in an active war zone and a major economic contraction due to the Russian invasion (nearly 30% reduction in GDP in 2022 alone, according to the World Bank); however, it is seen as reversable after the invasion given that OAT is included in the state-assured medical guarantees. Moreover, a special multi-sectoral working group, chaired by the Deputy Minister of Health, continues to oversee the scale up of OAT, despite the active war. In 2020, Moldova had most clarity from which sources, and how, OAT will be sustained financially and programmatically; however, since then, the transition plan has expired and was seen as not needed when the new national strategic plan on HIV was adopted. The assessment found that while there was no reversal in the progress of ensuring financial sustainability of core services and medications from the national budget, plans for transition of psychosocial support have stalled. In contrast, Tajikistan is yet to approve and cost its transition plan; while OAT is nearly exclusively supported by the Global Fund together with U.S.-funded sources and programmes, there is no vision and planning as to how this will transition into state systems. According to the assessment in 2022, OAT was not a priority in Tajikistan for either the Ministry of Finance or other state bodies and no transition was expected for some 5 years. In Belarus, a transition plan for the Global Fund supported programme was approved in 2020, together with a costed national HIV strategy with commitments to fund OAT medications and to expand the OAT programme. This transition plan has had a multifaceted positive influence: the development of an instrument on procedures which could unify standards and operation, likely improving the attractiveness of OAT; organising regional round tables to discuss service integration and sustainability; and more frequent dialogue between the ministries of health and interior to discuss OAT.
Dimension of ‘Finance & Resources’
Four indicators – ‘Medications’, ‘Financial resources’, ‘Human resources’ and ‘Evidence & information systems’ – comprise the dimension of ‘Finance & Resources’.
Table 4: Scoring of indicators for ‘Finance & Resources’
Indicator
|
Medications
|
Financial resources
|
Human resources
|
Evidence & information systems
|
Years
|
2020
|
2022/23
|
2020
|
2022/23
|
2020
|
2022/23
|
2020
|
2022/23
|
Belarus
|
Substantial (74%)
|
High
(78%)
|
Moderate
(61%)
|
High
(97%)
|
Moderate
(69%)
|
Moderate
(56%)
|
Substantial
(71%)
|
Moderate
(61%)
|
Moldova
|
Substantial (77%)
|
High (92%)
|
Substantial (79%)
|
High (88%)
|
Substantial (70%)
|
Moderate (56%)
|
Moderate (62%)
|
Moderate (68%)
|
Tajikistan
|
Moderate
(67%)
|
Moderate (50%)
|
At high risk
(13%)
|
At high risk (22%)
|
Moderate
(50%)
|
At moderate-to-high risk (42%)
|
Moderate (54%)
|
At moderate-to-high risk (49%)
|
Ukraine
|
Moderate
(61%)
|
Moderate
(56%)
|
Moderate (65%)
|
At moderate-to-high risk (49%)
|
Moderate (64%)
|
Moderate (56%)
|
Substantial (78%)
|
High (92%)
|
The ‘Medications’ indicator achieved a high degree of sustainability in 2022/2023 in Belarus and Moldova, increasing from a substantial degree in 2020. In Ukraine and Tajikistan, this indicator was scored as moderate in both 2020 and 2022-2023. By 2022, methadone and buprenorphine became part of the state essential or reimbursed medicine lists in all four countries. At least one manufacturer has registered their medication in each country, though in the case of Tajikistan, it was reportedly only the liquid form of methadone (and not the cheaper powder-based medication) that was being supplied. Belarus scoring had changed since 2020 because of two factors: methadone and buprenorphine were added to the national reimbursed medicine list and, in the second half of 2022, the national procurement of OAT medicines used a domestic standard process for the first time, abandoning the previous parallel system for internationally funded products. This switch has, however, caused interruption of buprenorphine access and necessitated the temporary switch of buprenorphine clients to methadone. Similarly, Moldova improved OAT sustainability by starting to fund buprenorphine from the national health insurance budget, though reporting some challenges with limited stock due to increased price. The limitation of Moldova’s sustainability is that the medications are funded by the state only for the Right Bank of the Dniester River, without a viable plan on how to ensure access in the non-government-controlled territory in the Left Bank[4]. The United Nations Development Programme (UNDP) continues to procure methadone for Tajikistan. Buprenorphine, while been included in the List of Essential Medicines by the Ministry of Health and Demography since 2018, was yet to be used in practice. In 2020-2021, Ukraine sourced methadone and buprenorphine through international open tenders to achieve best price, while paying for them from the domestic public budget. Two domestic manufacturers were offering the best price and were chosen to procure from up until 2022, when one of these manufacturers, located in the active war zone, was no longer able to function. In 2022, the procurement system changed as the Global Fund and U.S. PEPFAR had to step-in to fund medicines due to the major deficit in the state budget. In 2020, Ukraine’s assessment reported challenges with the supply chain – overstocking in some regions and insufficient stocks in others, without the possibility to move medicines between regions due to narcotics and stock management regulations. This changed in response to the war-related challenges, with the implementation of a more flexible, dynamic approach to the supply system which accounts for the fluctuating number of clients due to their migration and closure of some private providers.
In terms of ‘Financial Resources’, as of 2022, both Belarus and Moldova stood out as the most self-reliant countries. In Moldova, universal health coverage (UHC) has been implemented for OAT, with people accessing the medicine with or without a national health insurance certificate, as part of the Unified Health Care Programme. The national health insurance company covers medical services and administrative and operating costs, while the Ministry of Health covers the medication. The financial projections plan for the doubling of the number of clients (all state funded) from 2022 until 2025 and the first funding by the self-proclaimed government in the non-government-controlled area starting from 2024 where the Global Fund has been covering the costs. The scheme also works for people who use drugs without health insurance; however, it is limited to the territory under government control (i.e. not on the Left Bank of the Dniester River). In Belarus, all narcology support is included in UHC under the list of State-guaranteed minimum social standards in health care and is funded from the general narcology budgets. Since 2015, OAT sites received public funding, while methadone and buprenorphine were still purchased through Global Fund country grants until 2022. In 2019, targeted financing of OAT medicines began from the budget of the government programme, ‘People's Health and Demographic Security in the Republic of Belarus’ for 2016–2020 and for 2021-2025, i.e. medication funding remains programmatic, though they are part of the reimbursed medicine list. Even in the highest scoring countries – Belarus and Moldova – there are significant elements that continue to depend on donors and limited, if any, plans as to how these will be supported in the future, particularly in terms of indirect costs associated with OAT, such as technical support, advocacy, data and information systems but also psychosocial support, as indicated in Table 5. The Government of Ukraine took over financing of OAT medications and care from international donors, with acceleration in 2018, when it launched its Transition Plan 20-50-80, setting financial milestones for transition of HIV prevention, HIV care support and OAT41. Since 2020, OAT had been included in the state guaranteed packages of care funded through the single strategic purchaser (National Health Service of Ukraine) and during the health reform transformations its funding method and rates changed, resulting in the loss of some smaller providers from primary care. However, Ukraine’s rating of sustainability dropped in 2022 due to the Russian invasion in that year. The war and associated infrastructure destructions dramatically reduced the state’s income and economy, not only moving the funding for medicines back to donor support but also resulting in decreased predictability of the state’s economic prospects at large and its ability to fund OAT. Among the four countries, Tajikistan scored lowest for the indicator of ‘Financial resources’ as its medicines and a significant portion of development and running costs come from international donors. Its assessment was confronted with major data gaps. For example, the assessment and re-assessment had not managed to identify financial data on the state contribution to OAT from the Ministry of Health and Social Protection of the Population, nor financial information on the OAT-related activities listed in the ‘Implementation Plan of the National Programme to Combat the HIV/AIDS Epidemic in the Republic of Tajikistan for 2021–2025’. For example, it remained unclear which departments of the Ministry of Health and Social Protection of the Population were responsible for those OAT-related measures.
In 2022, the ‘Human resource’ indicator was rated at similar levels across the four countries, with a moderate degree of sustainability in three countries and at moderate-to-high risk in Tajikistan; however, each country reported significant insecurities in the long term. In all of the assessed countries, the initiation and management of OAT requires the presence of a physician specialising in dependence treatment, who is called a narcologist or a psychiatric narcologist. Yet, there is a shortage, underutilisation and aging of these specialists to varying degrees in the four countries. For example, in Tajikistan, narcologists are included in the state’s list of specialties with an insufficient number of experts; just 6 out of 15 OAT sites in primary care centres have an onsite narcologist. In Ukraine, only 6% of registered narcologists were engaged in OAT as of 2017. The staffing challenge is less visible in Belarus, though it is emerging in some regions. In Moldova, refusal of the two narcologists to practice OAT led to the closure of two sites in the last 5 years as they were the only narcologists in the location. Only Ukraine has an OAT development plan to train primary care doctors in OAT provision and to expand the number of experts who can practice this approach. Moreover, Ukraine has defined standard packages and incentives for the decentralisation of OAT delivery, including primary care, which has increased the opportunities of the most accessible level of national health care system in offering OAT to their clients. In Belarus and Moldova, engaging non-narcologists and non-specialised drug treatment providers (such as health workers at primary mental health care centres in the case of Moldova) or private providers or pharmacies for the dispensing of OAT medicines is not even on countries’ agenda. Nevertheless, all four countries reported significant investments in capacity building of health professionals directly involved in OAT that has been supported by international donors over recent years. Both Belarus and Moldova assessments reported on active supervisory support as of 2022. In Moldova, OAT is integrated into graduate courses and a professional association is active to provide post-graduate support. However, in Belarus, Tajikistan and Ukraine, OAT mainly relies upon postgraduate courses. As the Ukrainian assessment found, OAT is mentioned in graduate studies only superficially and continues to be portrayed as an allegedly inferior approach to drug dependence management when compared to abstinence-oriented methods. Similarly, in Belarus, OAT is not fully integrated in the professional training of narcologists, nurses and infectious disease doctors. Additionally, both in Moldova and Tajikistan, OAT practitioners highlight low renumeration for staff. In the case of Moldova, while previous Global Fund-sponsored bonuses for OAT delivery for staff were removed, health workers still consider OAT as an additional duty for which they should be paid extra. In Tajikistan, donor supported incentives – linked to results – had driven the focus of practitioners to recruiting new clients, and, when unachieved, reduced the de facto payments received, and led to low retention of staff, especially in smaller sites.
In both 2020 and 2022, Ukraine made particularly substantial progress in building their ‘Evidence and Information Systems’, including open-data M&E, eHealth information system with confidentiality protections and locally generated research and evaluations. Belarus, too, reported a strong local capacity in place for assessing OAT with one doctoral study and operational reporting by the Republican Scientific Applied Research Centre for Mental Health and ongoing digitalisation. However, the country reports a lack of studies on implementation efficiency, which is critical for the successful transition from donor support. Since 2020, the indicator’s rating of the country decreased due to the impact of COVID-19 on research involving clients. Moldova remained stable for the indicator of ‘Evidence and Information Systems’ with some improvements following the establishment of a register of OAT clients to improve data exchange across sites; however, as of 2022, it was still to be expanded outside the capital city. The country’s last comprehensive evaluation took place more than 10 years ago. The continued challenges with analysing data, including OAT outcomes and the quality for strategic and operational OAT development, are linked to the absence of one state agency that would be charged with the development and organisational support of OAT. In Tajikistan, the electronic programme registry was put in place in 2015; however, there are no regular reports on OAT in a public domain and, out of the 8 studies related to OAT in the last 10 years, none were conducted in the last 4 years. On the positive side, all the assessed countries had increased OAT client-led monitoring and service quality assessments between 2020 and 2022. In Moldova, client satisfaction was the only study implemented in the last 3 years.
Across the four countries, the indicator ‘Evidence and Information System’s’ generally continues to depend on international funding and technical support.
Dimension of ‘Services’
In the ‘Service’ dimension, among the three indicators, the highest degree of sustainability is recorded for ‘Accessibility’, closely followed by ‘Quality & integration’, with ‘Availability & coverage’ continuing to lag, as shown in Table 6.
Table 6: Scoring of indicators for ‘Services’
Indicator
|
Availability & coverage
|
Accessibility
|
Quality & integration
|
Years
|
2020
|
2022
|
2020
|
2022
|
2020
|
2022
|
Belarus
|
At high risk
(8%)
|
At high risk
(17%)
|
Moderate (62%)
|
High
(85%)
|
Moderate
(54%)
|
Substantial
(71%)
|
Moldova
|
At moderate-to-high risk
(37%)
|
At moderate-to-high risk (42%)
|
Moderate
(69%)
|
Substantial
(83%)
|
Moderate
(66%)
|
Moderate
(67%)
|
Tajikistan
|
At high risk
(17%)
|
At high risk (17%)
|
Moderate
(69%)
|
Moderate
(57%)
|
Moderate
(58%)
|
Moderate
(50%)
|
Ukraine
|
At moderate-to-high risk (30%)
|
Moderate (54%)
|
Moderate
(67%)
|
Substantial
(70%)
|
Moderate
(69%)
|
High
(88%)
|
Additionally, Table 7 provides an overview of several key benchmarks across the Service dimension.
Table 7: Selected OAT markers for the ‘Service’ dimension (latest data reported in the 2022-2023 national assessments)
|
Belarus
|
Moldova
|
Tajikistan
|
Ukraine
|
Population
|
9.2 million (2022)36
|
4.2 million
|
>10 million (2022)
|
41.2 million[5] (2022)37
|
Number of people with opioid dependence in state drug treatment system or registered by the system
|
4,579 (2020)
|
11,575 (all psychoactive substances) (2022)
|
4,749
(December 31, 2021)
|
n/a
|
Estimated number of people who use opioids (alternatively, estimated number of people who inject drugs)
|
73,800 and 87,000 people (2020)
|
12,920 (2020)
|
22,208 (2018)
|
270,800 (2022)
|
Medicines used for OAT
|
Methadone, buprenorphine
|
Methadone, buprenorphine
|
Methadone (liquid)
|
Methadone, buprenorphine, start of the use of long-acting buprenorphine in January 2023
|
Availability and coverage
|
Coverage of the estimated number of people with opioid dependence or people injecting drugs
|
4%
|
5.5% (2022)
|
3%
|
9.4%
[7.3% in February 2022, at the beginning of the Russian invasion]
|
Number of OAT clients
|
707 (end 2021)
|
590 (September 2022)
|
614 (December 2022)
|
27,432 (December 2022) [20,331 in February 2022, at the beginning of the Russian invasion]
|
Number of OAT sites (excluding penitentiary system)
|
20 (end 2021))
|
11 sites in 10 cities (September 2022)
|
15 sites (December 2022)
|
207 sites (end of 2022)
[224 sites in February 2022, at the beginning of the Russian invasion]
|
Percent of administrative units with OAT
|
100%
|
29%
(10 out of 34 administrative units), excluding non-government-controlled area
|
100%
|
100%, excluding the temporarily occupied territories
|
The share of clients receiving OAT in state specialised drug treatment or mental health institutions
|
100%
|
100%
|
100%
|
51.5%
|
Take-home dosages upon clinical prescription
|
Yes
|
Yes
|
No
|
Yes (provided to around 90% of all clients)
|
Availability in primary care and hospitals, licensed private sector and NGOs
|
Hospitals
|
Hospitals
|
-
|
Hospitals, primary care, private sector (around 27% of all clients)
|
Availability in penitentiary settings
|
Pre-trial detention only upon special approval
|
Pre-trial detention, 13 correctional facilities including for females
|
2 penitentiary institutions
|
Pre-trial detention; 7 penitentiary institutions (including one for females and one for juvenile offenders)
|
Quality and integration
|
Recommended dosages in clinical guidelines
|
Minimum 60mg for methadone and 12mg for buprenorphine.
No restrictions on maximum dosage
|
Methadone: 60-120mg; Buprenorphine: 16mg
|
Minimum 60mg for methadone and 12mg for buprenorphine. No clinical restrictions on maximum dosage; the operational guidelines recommend a maximum of 200mg of methadone and 16-24mg of buprenorphine
|
Minimum 80mg for methadone and 8mg for buprenorphine
|
Average dosage of methadone, buprenorphine
|
Methadone: >=60mg
Buprenorphine: >=12mg
|
Methadone: >=50mg by 87% clients in one site and 76% of clients in a study in 2021;
Buprenorphine: 8mg in one site and a study in 2021.
|
Methadone: ≥60mg received by 46% (data from 6 out of 13 sites)
|
Methadone >=80mg in 86% of medical facilities;
Buprenorphine: >=8 mg/day or more in 93% of facilities.
|
Retention (% of clients on therapy for 6 months or longer)
|
67%
|
65%
|
65%-100% in 2022 (data from 12 out of 13 sites)
|
70–80% in 2022
|
Number of HIV or TB specialised services that provide OAT
|
0
|
0
|
0
|
21 (and 139 multidisciplinary hospitals)
|
Share of OAT sites with integrated care for HIV/TB/HCV
|
30%
|
27%
Only 3 sites in civil sector (out of 11) integrated into a comprehensive framework and/or interacting with other services
|
60%
|
All state funded sites are expected to provide linkages to other services;
53% of OAT clients reported the availability of additional services at OAT sites
|
For the indicator ‘Availability & coverage’, Ukraine reported the greatest progress across the three indicators since 2020 and became the only country reaching a moderate degree of sustainability. This progress was driven by two developments during 2020-2022. Firstly, OAT became better integrated into the broader health system, as 64% of all OAT clients received this service outside of specialised narcology institutions. The private sector became eligible to receive state funding for delivering OAT services and its increased role in OAT services was duly reflected in state statistics. Secondly, in response to COVID-19 restrictions in 2020, and later due to the full-scale invasion of Ukraine by Russia in 2022, the uptake of take-home doses increased and more clients became entitled to such much-needed flexibility. As a result, as of 2022, up to 92.8% of OAT clients benefitted from this approach, up from 52.9% in 2019. OAT remained absent in Ukraine’s territories occupied since 2014 (Crimea, and parts of Donetsk and Luhansk regions) and newly occupied territories in 2022-2023. However, OAT was re-established, for example, in the Kherson region after its liberation by Ukraine’s armed forces38.
Moldova started allowing self-administration and video-observed administration of OAT in 2020 during the COVID-19 pandemic’s first wave. In August 2021, the Belarus Ministry of Health allowed ОАТ providers to pass the medicine to in-patient clinical settings and to issue the medicine for self-administration by clients as per the new resolution, ‘On medical care for clients with dependence on narcotic drugs of the opium group’. Previously, even during the COVID-19 pandemic, OAT could not be administered in hospitals and required daily site visits by clients. Tajikistan remains the only country without take-home doses as there is no specific instruction agreed between the health and interior authorities.
In all of the countries, OAT coverage is well below the level of at least 40% of the estimated number of people with opioid dependence that is recommended by WHO for preventing the transmission of HIV and other infections. Only Ukraine shows accelerated growth in coverage with 17% of new clients enrolled in 2022, reaching 10% coverage. Moldova is the only country that has OAT across criminal justice settings, while Tajikistan offered OAT in two prisons for convicted individuals with the plans signed by the Minister of Justice to expand it, and Ukraine started pilots in male and female prisons.
The Accessibility indicator had improved across all countries between 2020 and 2022-2023, with some important gains achieved before the studied period. Already in 2020, the four countries did not require proof of previously failed drug treatment in order to access this treatment modality (which used to be a common requirement at the initial stages of OAT roll-out before the period studied). Neither guidelines nor general practice automatically exclude clients because of concurrent illicit drug use in any of the studied countries in 2020 or 2022-2023. Pregnant women were allowed and encouraged to take OAT. In general, the minimum age of clients accepted into the programme started from 18 years, according to assessments and re-assessments in the four countries. Additionally, Belarus foresaw exceptional cases to initiate this therapy at 16 years of age, and Tajikistan allowed entry for clients under the age of 18, with parental consent. In all countries, co-payments were largely eliminated with some exceptions remaining in Tajikistan on diagnostics needed for OAT initiation, or in Ukraine, where some clients reported the need to pay a bribe to enter the programme as of 2022. Ukraine was the only country explicitly reporting waiting lists in some facilities in 2022. Mandatory narcological registration of clients by state institutions serves as the key barrier to accessibility in Belarus and Tajikistan, while Ukraine had eliminated this practice already before 2020. In all of the countries, all of the main administrative regions had at least one OAT site (except for temporarily occupied, non-government-controlled, areas). Geographic expansions between 2020 and 2022 were reported in Belarus and Moldova. However, physical accessibility was an issue in the four countries. Geographic distribution was uneven, with the service network underdeveloped in some regions. It was particularly challenging in the countries where take-home doses were not broadly practiced, especially when high numbers of people were in need in smaller towns and where services operated with short working hours. Physical access is acute in mountainous areas of Tajikistan bordering Afghanistan where opioid use was highly prevalent. As of the end of 2022, no mobile services were available, except for home delivery of medicines for people with mobility restrictions in Ukraine, and transportation costs are not reimbursed in any of the four countries. In three out of four states (Belarus, Moldova and Tajikistan) as of 2022-2023, OAT clients were often dissatisfied with site working hours. The national assessments found a great variation in operating hours depending on sites and their staffing.
Each country reported both good practices and challenges under the indicator of Quality and integration pertaining to ‘Service’ dimension. Ukraine achieved a high degree of sustainability, followed by Belarus with a significant degree, while in the other two countries this indicator was rated as moderate. The minimum recommended doses differ in the four countries – all set at 60mg for methadone, except for 80mg in Ukraine. However, for buprenorphine, Ukraine’s OAT programme, which is the most experienced with this substance among the four countries, has the lowest minimum dosage (8mg), as detailed in Table 7. No country had restrictions for increasing dosage, or for the duration of OAT. Despite the lack of ceilings for dosage, in Moldova, a survey among clients during 2021-2022 showed that three-quarters of clients were satisfied with their dosage, but another 25% thought their dosage was insufficient. In Tajikistan, the integration of OAT with HIV and tuberculosis services began in 2014 in the largest sites, where now the practice of provision of ART and TB medications is continuing without additional technical support; however, its financial support was cut and, therefore, sites can no longer afford to second doctors to provide a one-stop-shop for OAT, TB and antiretroviral therapies. In Ukraine, 53% of clients in one national survey reported access to other on-site services, including 34% to ART and 22% to hepatitis C treatment. In Moldova, people-centred approaches are a priority for the national health system. However, TB treatment is provided in just one OAT site, while TB preventive treatment for OAT clients was disrupted in Balti in 2020. In Belarus, social peer-led support was introduced in 2019 with NGO support; a similar service has been provided in Ukraine and Moldova for years. Ukraine takes advantage by integrating mental health screening in OAT packages. In Belarus, psychological support has been expanded from 8 consultations per client per year reported in 2019 to an average of 13 in 2020. In Tajikistan, there was a psychologist at only one site. OAT quality was reported to be uneven within the countries; it was mainly considered better, with more competent and less stigmatising staff, in larger cities. According to findings from Tajikistan focus groups and data analysis, low quality at two sites was the reason for low uptake of OAT, resulting in lower retention (65%) compared to 100% retention at some sites with good quality. In one survey in 2020 in Moldova, as identified by the national assessment, 27% of OAT staff preferred not to work with OAT clients and prioritised detoxification and the so-called will-power interventions to address drug dependence over OAT, despite national guidance. This, among other things, is reflective of high stigma of OAT among staff and in societies that has been generated over time within the analysed countries and continues to be fueled by, as some respondents reported, widely available anti-OAT Russian-language resources.
Areas of progress and challenges
None of the four countries reported a high degree of OAT sustainability in either of the three dimensions. However, a high degree of sustainability was reported at least for one indicator in three countries: Medicines (Belarus, Moldova); Financial resources (Belarus, Moldova); Evidence and information systems (Ukraine); Service Accessibility (Belarus); and Service integration & quality (Ukraine). Overall, the highest improvement between 2020 and 2022 was seen for Availability & coverage, Financial resources, Service quality & integration and Service accessibility. The list of the indicators that improved reflects the directions of advocacy efforts from experts, clients, donors and technical partners to improve services and financial transition. Two of those reported directions are the inclusion of OAT in the financing of UHC schemes and donor requirements for co-financing. Additionally, significant efforts by health professionals and organised networks of OAT clients have prioritised service improvements, which is demonstrated by the increased number of community-led research and inclusion of client perspectives in local surveys.
The greatest risks across the countries, in particular in Belarus and Tajikistan, were recorded for Service Availability and coverage indicator. Those risks were exacerbated by the low coverage - below 10% - in the four countries at the time of the assessments, as well as the limited availability of OAT outside public sector’s specialised narcology facilities and, in some countries, the ongoing low use of take-home doses. Of concern is that the least progress, or even a decline, in the Human resources indicator is affecting the OAT sustainability.
[3] In mid-2021, Tajikistan and Moldova were reclassified by the World Bank, moving Moldova from lower-middle to upper-middle income category and Tajikistan from a low income to lower-middle income country. The estimated income level is significantly different within the categories; for example, based on the World Bank’s preliminary estimates, in 2022, Ukraine’s gross national income per capita was nearly 4 times higher than in Tajikistan.
[4] The Left Bank of the Dniester is an administrative unit of the Republic of Moldova which, since military conflict and ceasefire in 1992, has been outside the Moldovan government’s control and has been governed by a Russia-backed self-proclaimed and unrecognised government.
[5] The estimate of the general population is based on the pre-war situation in Ukraine before February 2022. A more realistic estimate is significantly smaller due to the forced displacement of nearly one third of Ukrainians including those who had to flee the country after the full-scale war has started.