Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023

Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023 Raminta Stuikyte, Ivan Varentsov, Sergii Dvoriak, Myroslava Filippovych, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4021071/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Oct, 2024 Read the published version in Harm Reduction Journal → Version 1 posted 10 You are reading this latest preprint version Abstract Background Most national programmes of opioid agonist therapy (OAT) in Eastern Europe and Central Asia are at a critical juncture for building their sustainability due to decreasing support from the Global Fund and other international HIV funders. Therefore, it is timely to identify the status, trends, opportunities and risk factors of OAT preparedness in the face of donor transition. Methods The study assessed the OAT sustainability progress in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine. The national assessments were conducted in 2020 and repeated during 2022–2023. In total, 363 sources were reviewed and used, 83 interviews with key informants and 13 focus groups were conducted with clients, using a joint methodology and a defined Framework with three dimensions: ‘ Policy & Governance ’; ‘ Finance & Resources’ ; and, ‘ Services’ . Results All four countries have made improvements to increase OAT sustainability, though it varied. 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 achieved a high degree of OAT sustainability in any of the three dimensions measured. However, a high degree of sustainability was reported for at least one indicator in Belarus, Moldova and Ukraine: ‘ Medicines’ ; ‘ Financial resources’ ; ‘ Evidence and information systems’ ; ‘ Service Accessibility’ ; or, ‘ Service integration & quality’ . On average, the greatest improvement between 2020 and 2022 was seen for ‘ Availability & coverage’ ; ‘ Financial resources’ ; ‘ Service quality & integration’; and, ‘ Service accessibility’ . The highest risks across the countries, notably in Belarus and Tajikistan, were recorded for the indicator, ‘ Availability and coverage’ . Of concern is that the least progress, or even a decline, was found in ‘ Human resources’ within the sustainability indicator. Conclusions OAT sustainability in 4 analysed countries remains at risk, although those countries are at a different point of donor transition. OAT resilience and ability to scale up depend upon multiple factors. Political will and continued funding are two of them, as demonstrated by Ukraine’s progress despite challenges posed by Russia’s full-scale invasion in 2022. The results show that both financial and programmatic areas are at risk and stagnating progress requires collective efforts. Opioid agonist therapy methadone buprenorphine injecting drug use Eastern Europe Central Asia drug treatment transition sustainability Figures Figure 1 Background Opioid agonist maintenance treatment, or opioid agonist therapy (OAT)[1], combined with psychosocial assistance, is the most effective modality for managing opioid dependence, recommended by the World Health Organization (WHO) 1 . In addition to its function as drug treatment, OAT is part of the core interventions for preventing and managing HIV and the hepatitis C virus among people who use drugs 2,3,4 . Methadone and buprenorphine are part of the WHO Model List of Essential Medicines 5 . Globally, 87 countries implement OAT 6 . In Eastern Europe and Central Asia (EECA)[2], OAT remains fragile from the policy, programmatic and financial perspectives. OAT remains unavailable in the Russian Federation, Turkmenistan and Uzbekistan. In addition to legal prohibition of this treatment option, Russia’s foreign policy and law enforcement are explicitly against OAT, which is significant given this country’s security, economic, and other influence in the region 7,8,9 . In all of the 12 EECA countries with OAT, this care modality was introduced with international donor support, mainly for tackling the HIV epidemic among people who inject heroin and other opioids 10,11,12 . The leaderships of state drug treatment services (called ‘narcology’ in those countries) and law enforcement has often resisted OAT, arguing that total abstinence should be the main goal instead 7,13,14,15 . Notwithstanding severe HIV epidemics associated with unsafe drug injecting in the EECA, OAT programmes have faced the challenge of being a ‘perpetual pilot project’ 16 , i.e. being given the status of a pilot over multiple years without systemic scale-up and/or change in status. Currently, only Estonia, Georgia, Latvia and Lithuania fully fund this drug care modality from domestic public resources. The scale of, and access to, OAT remains a concern. According to the latest available data in 2023 17,18 , just one EECA country, Georgia, has achieved coverage at the WHO-recommended medium range. Furthermore, donor-funded HIV operations often involve parallel systems and arrangements for procurement and the supply of health products; payments and training of staff; health information; and financing. While, in certain instances, designed and introduced under justifiable circumstances, such as widespread corruption in national health sector 19,20 , those parallel arrangements are not sustainable and can lead to poor transition without integration into domestic systems and domestic capacity building completed prior to donor phase out 21 . Sustainability of health responses dependent on donor funding is a major concern, especially in the HIV field, where international support is flatlining 22,23,24 . The Global Fund, the major international OAT funder in the EECA region, expects a focus on sustainability and transition preparedness from all lower-middle income countries with a lower disease burden and upper-middle-income countries, including all those EECA countries eligible for Global Fund’s HIV funding. This focus should include enhanced transition planning, increased focus on sustainability of interventions for HIV among key and vulnerable populations and accelerated co-financing 25 . Therefore, a reasonable assessment of the OAT status in the EECA is timely to identify trends, risk factors and transition preparedness in the face of reduced international support. [1] This treatment is known under different names in scientific literature, country policy documents and among practitioners including opioid substitution therapy and medically assisted therapy; however, because of stigma and politicisation attached to the first name, and the inaccurate distinction from other approaches in the second, this article uses the name of OAT. [2] For the purposes of this article, the region of Eastern Europe and Central Asia refers to the 15 states that (re)emerged after the collapse of the Soviet Union in the 1990s and includes Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. Methods The purpose of the study was to assess the progress and risk areas of building sustainability of OAT programmes in 4 EECA countries (Belarus, Republic of Moldova, Tajikistan and Ukraine) in the context of transition from Global Fund financial support to public funding and systems. Based on the results, the study aimed to develop recommendations for national authorities, OAT managers, advocates, international partners and donors, like the Global Fund, on maintaining and expanding OAT programmes in the new environment. The OAT sustainability assessment in these 4 countries was conducted in 2020 and then repeated during 2022-2023 in order to monitor the changes in sustainability over time. Instrument for measuring OAT sustainability The study utilised an OAT-specific instrument for measuring the degree of, and opportunities for, sustainability of OAT. The Eurasian Harm Reduction Association (EHRA) developed and supported the testing of this instrument during 2019-2020, as described in a separate article 26 . The instrument is applicable for the implementation at the national level. It measures three dimensions of programmatic, financial and other aspects of sustainability: Policy & Governance; Finance & Resources; and Services. Each dimension is measured through 2-4 indicators that are composites of benchmarks. Dimensions and corresponding indicators in each dimension are calculated using a 6-rank scale as shown in Figure 1. In addition to measuring dimensions and indicators, the instrument requires the compilation of qualitative and other quantitative data to analyse trends, challenges and opportunities for the improved sustainability of OAT. National assessments To gather inputs for the regional study, EHRA commissioned and led the national assessments by implementing the instrument for measuring OAT sustainability. The country selection prioritised the three countries where the instrument was piloted during 2019-2020. Moldova became the fourth country selected due to significant advocacy opportunities. Each in-country assessment in 2020 and re-assessment during 2022-2023 were conducted by a national consultant selected through a competitive process. Ukraine was an exception as its lead expert was part of the advisory body that supported the development of the instrument. The national consultant was supported by a country-specific multi-stakeholder Advisory Group in all assessments and re-assessments, except Ukraine in 2023. In all countries, national results validation involved a national workshop and/or a review of the report by national stakeholders. EHRA provided technical support for the in-country assessment and facilitated the discussion of the results with national stakeholders. Each national assessment conducted a desk review of legal, policy, clinical and programmatic data, followed by key informant interviews and focus groups with OAT clients to triangulate the data and, where needed, an expert assessment. Data inquiries were placed with various institutions and management organisations to address data gaps in the public domain. In total, across the 4 countries and in the two time periods, the assessments reviewed 363 sources, conducted 83 interviews with key informants and 13 focus groups with OAT clients, as detailed in Table 1 . In the case of Ukraine’s assessment during 2022-2023, two data points were collected for most data-related indicators – one for the status before Russia’s full-scale invasion in Ukraine in February 2022 and other at the end of 2022; however, the national consultants that led the scoring of OAT sustainability based their findings on the most recent data available which, in most cases, was the status after the full-scale war had started. Compiling results for the regional study The compilation of the regional results from all the country assessments and re-assessments relied on the 8 national reports that underwent validation. Therefore, this manuscript did not refer to the primary sources of information used by the country assessments. Instead, it used secondary sources, i.e. the eight validated national assessment reports. Additionally, EHRA archived files with primary and secondary data and analysis to ensure availability and transferability of all scoring and qualitative information over time. This archiving practice was particularly helpful in one country (Tajikistan) where two different consultants conducted the assessment in 2020 and the re-assessment during 2022-2023. The country reports are available online 27,28,29,30,31,32,33,34 . Results 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 services 35 . 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 OAT 41 . 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 forces 38 . 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. Discussion OAT remains at risk during the process of transition from donor support to domestic funding in Eastern Europe and Central Asia. Globally, in 2019, only 9% of the UNAIDS-estimated funding required for OAT and other harm reduction interventions was available in low- and middle-income countries, coming in equal portions from domestic public resources and donors 39 . As the World Bank classification of income status remains the cornerstone of eligibility and the funding allocation formula for donors such as the Global Fund, countries of the EECA region, as well as other middle-income countries, are advancing closer to transition and ineligibility in the continuum of donor support. While the four analysed countries rolled out OAT programme at similar times, their development pace and approach vary and are country specific. OAT is increasingly recognised as part of the core care, with state funding invested in all the middle-income countries analysed; however, there is limited will to scale it up and to address the real need. All countries have clinical guidelines and clinical leadership on OAT from the drug treatment system. However, the political support and the accountability mechanisms for scale-up and domestic investments continue to draw mainly from the national HIV strategies, programmes and budgets (and not the drug strategies and budgets). This assessment highlights both positive and negative elements of the reforms. For example, in Ukraine, the transition to domestic funding and changes to the payment methods in 2020 meant that the previous generous financial incentives to providers were replaced by less economically attractive fees for service managers, and some smaller sites discontinued services; nevertheless, the overall number of clients has increased. The health financing and organisational reform in Ukraine had led to significant changes in narcological care and enabled the greater integration of OAT outside of specialised settings, probably making Ukraine the leader in decentralisation and integration in the region. Critical factors for utilising this broader health reform for OAT progress were seen in having a clearly-mandated institution that was responsible for OAT development and in the presence of the high-profile, open-minded, multisectoral group that supported that development politically and technically. On the flipside, in Belarus, Moldova and Tajikistan, the health system strategies aim to strengthen primary care and UHC; however, they are yet to break the barriers for OAT expansion through general practitioners and other non-narcological care. Moreover, across the four - and other - countries in the EECA region, the national HIV and TB programmes have been subject to regular systemic programmatic reviews by WHO at the request of ministries of health. This scrutiny of the national HIV programmes aims to improve their value for money, including their efficiency 40 . In contrast, the narcology system - where management of opioid dependence, including OAT, are just one of the functions - has not been subject to similar reviews of their effectiveness and efficiency for realistic public health goals and for setting roadmaps for their reform. The territories in active war or frozen conflicts, like those in Ukraine and Moldova, require a different timeline for donor exit and collective solutions and, in the case of OAT, might not be possible without broader geopolitical changes. For example, since 2014, when self-proclaimed Russia-backed separatists took power in Eastern Ukraine, access to antiretroviral therapy (ART) and TB treatments depended on international humanitarian support. Once the humanitarian channel became unworkable and stocks ran out, in 2023, the Russian Federation started funding ART in Donetsk, reportedly subject to accepting Russian citizenship 41 . Moreover, OAT is unavailable in the non-government-controlled areas of Moldova and temporary occupied territories of Ukraine where Russia-installed de facto authorities replicated Russia’s anti-OAT stance. The COVID-19 pandemic shifted the focus of many health programmes to the emergency response; therefore, it somewhat weakened the attention to donor transition-related planning, at least in some settings. Nevertheless, evidence from the three countries showed the pandemic’s progressive influence on health sector’s emergency response preparedness also allowed for the decentralisation of OAT provision, including greater self-care, in alignment with WHO recommendations. Transition planning and management of the national HIV programmes have had a positive role in increasing the sustainability of OAT, by presenting a vision and plan for sustaining various elements, particularly financial resources, of OAT. Furthermore, the multi-sectoral approach of HIV governance and transition can facilitate a dialogue across different ministries, including the ministries of health, finance and interior. This study outlines areas for further advocacy and support for greater self-reliance of OAT, some less articulated in the national programme documents. The study highlights the human resource challenges. There is a growing recognition of, and attention to, the need to address the general human resource crises in the health sector across Europe 42 ; however, this system building block has been understated in the sustainability and transition planning, so far, and should receive greater prioritisation in the future, including for OAT sustainability building. The inclusion of critical stakeholders in the assessments, either in the country-specific advisory groups and/or in the validation of reports, increased ownership and use of reports and the increased attention to sustainability risks at the country level, as highlighted in the article dedicated to the instrument which was used for this study for measuring sustainability of OAT 24 . Limitations Despite the emphasis on increasing objectivity, the country assessments had a degree of subjectivity and adaptation to various health systems and political contexts in their quantitative analyses. For example, Moldova’s 2022 reassessment narrowed the review of the indicator, ‘Management of transition from donor to domestic funding’, to one aspect of OAT, that of psychosocial support which remains funded by donors, while other core services and medication provision have been funded by the government for several years. In Belarus, Tajikistan and, to some extent, Moldova, desk reviews identified only a limited amount of public information; information was acquired through experts with access to internal databases, or through inquiries for information, or had to rely on expert opinions. This significantly impacted the speed of respective assessments. While the national assessments did not seek ethical committee approvals, the instrument development involved a multistakeholder group including a representative of the International Network of People who Use Drugs (INPUD) and WHO. Seven out of 8 assessments included OAT expert clients to inform the design, implementation and validation of the reports. In Tajikistan, in 2022, the assessment and its format, methodology and tools were formally agreed upon with the Ministry of Health and Social Protection of the Population (MoHSP) in addition to the advisory group. In 2023, Ukraine’s re-assessment did not involve an advisory group; however, the results were summed up with partners and the report went through a review process including by the Public Health Centre under the Ministry of Health and the Global Fund. The client perspectives have been included only to a limited extent. The Belarus assessments did not involve a focus group with a broader number of OAT clients; however, the 2022 re-assessment increased the number of OAT clients among key informants to shine a light on the satisfaction with quality and on barriers and opportunities for increased uptake. The limited number of focus groups in all countries meant that only clients from larger cities and sites were directly involved. Tajikistan was an exception and managed to engage direct views from smaller sites through a higher number and geography of focus groups. Conclusions OAT sustainability in the four countries remains at risk and requires further planning and management. The resilience of the OAT programmes, and ability to scale up, depend on multiple factors. Political will and continued funding are some of them. Ukraine exemplifies the ability to address both previously documented challenges, such as rigid stock management and high specialisation of service providers as well as new obstacles related to the country being at war and enduring a difficult economic period, demonstrating that building sustainability is not only about securing domestic funding. The country included OAT in its transition planning and health reforms which enabled it to secure state guarantees for this care, a true top leadership commitment to OAT and to the integration and decentralisation of this method for greater access, scale and people-centredness. The other three countries also showed important practices and lessons for building OAT sustainability which were closely interlinked with the uptake of the WHO and UN recommendations for these programmes. There is a need for an increased focus on programmatic elements of OAT sustainability - the resource inputs and service attractiveness across the four countries. The study offers a review of those needs and suggests pathways going forward. Some of the follow-up steps could benefit from cooperation and synergies with teams working on sustainability in the HIV and TB fields (such as medication procurement, UHC packages, multidisciplinary care and integration in primary settings). The collaborative approach to the assessment, with the engagement of key stakeholders responsible for OAT through an advisory group, has been proven to support greater follow-up and ownership which might affect the ability of a stronger articulation of recommendations. As these countries undergo major transformations and donor transition, similar and potentially simplified assessments may need to be planned in the countries. Finally, while COVID-19 had greatly impacted national health systems, the pandemic also enabled the adoption of measures to ensure greater accessibility of services. This could be seen as an opportunity for continuing the dialogue for more accessible, sustainably resourced and politically backed OAT. Abbreviations AIDS Acquired Immunodeficiency Syndrome ART antiretroviral therapy EECA Eastern Europe and Central Asia EHRA Eurasian Harm Reduction Association GDP Gross Domestic Product Global Fund Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria HIV Human Immunodeficiency Virus INPUD International Network of People who Use Drugs MoHSP Ministry of Health and Social Protection of the Population NGO Non-Governmental Organisation OAT Opioid Agonist Therapy TB Tuberculosis UHC Universal Health Coverage UNDP United Nations Development Programme UNODC United Nations Office on Drugs and Crime WHO World Health Organization Declarations Ethics approval and consent to participate Not applicable as the manuscript does not report on or involve the use of any animal or human data or tissue. Seven out of 8 national level assessments which results are being summarized in the maniscript involved a multistakeholder advisory groups (which included OAT expert clients) to inform the design, implementation and validation of the assessment reports. In 2023, Ukraine’s re-assessment did not involve an advisory group; however, the results were summed up with partners and the report went through a review process including by the Public Health Centre under the Ministry of Health and the Global Fund. All experts being interviewed for the assessment purposes and participated in focus groups in 4 countries signed informed consent forms. Consent for publication Not applicable as the manuscript doesn’t contain any individual person’s data in any form. Availability of data and materials The methodology and instrument used to conduct the assessments which results are being described in this manuscript are available online at: https://eecaplatform.org/en/oat-a-guide-for-assessment-in-the-context-of-donor-transition/ Data supporting the assessments’ results reported in the article can be found in: Iatco A. Republic of Moldova: Assessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. Vilnius, Lithuania: Eurasian Harm Reduction Association (EHRA), 2020. https://eecaplatform.org/en/ptao-v-moldove/ Kralko A.A., Republic of Belarus: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding. EHRA, February-April 2020. https://eecaplatform.org/en/oat-in-belarus/ Dvoryak, S, Zeziulin, A. Украина: Анализ устойчивости программ поддерживающей терапии агонистами опиоидов в контексте перехода от донорской поддержки к национальному финансированию. [in English: Analysis of the sustainability of opioid agonist maintenance therapy programme in the context of transition from donor support to domestic funding]. Kyiv, February-April 2020. https://eecaplatform.org/ptao-v-ukraine/ Latypov, A. Republic of Tajikistan: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding, EHRA, February-March 2020. https://eecaplatform.org/en/oat-programme-in-tajikistan/ Kralko A.A. Republic of Belarus: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, Lithuania, 2023. https://eecaplatform.org/en/oat-reassessment-belarus/ Malikov N (2023). Tajikistan: Reassessing the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. https://eecaplatform.org/en/oat-reassessment-tajikistan/ Iatco A. Republic of Moldova: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. https://eecaplatform.org/en/oat-reassessment-moldova/ Dvoryak, S, Filippovich, M. Ukraine: reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023 https://eecaplatform.org/en/oat-reassessment-ukraine/ Competing interests None. Funding United Nations Population Fund (UNFPA) and the Technical Support Mechanism of the Joint United Nations Programme on HIV/AIDS (UNAIDS) funded the development of the methodology and instrument used to conduct the assessments which results are described in the article. The sustainability assessment of the OAT programme in Belarus, Republic of Moldova and Tajikistan in 2020 were implemented with funding provided through the technical support mechanism (TSM) of the Joint United Nations Programme on HIV/AIDS (UNAIDS). The sustainability assessment of the OAT programme in Ukraine in 2020 was implemented with financial support provided by the International Renaissance Foundation. 2023 assessment reports were prepared by Eurasian Harm Reduction Association and published as part of the regional project, 'Sustainability of services for key populations in the region of Eastern Europe and Central Asia' (SoS_project 2.0), implemented by a consortium of organisations led by the Alliance for Public Health in partnership with the charitable organization '100% Life', with financial support from the Global Fund. The corresponding author received partial support for drafting the article from the Global Fund-financed project ‘EECA Regional Platform for Communication and Coordination’ through Eurasian Harm Reduction Association. Authors' contributions All authors discussed the concept and approach to the article. Raminta Stuikyte produced the first draft of the article. Ala Iatco, Myroslava Filippovych, Naimdzhon Malikov, Aleksei Kralko reviewed data cited and its interpretation for the corresponding countries. Ivan Varentsov, Alisher Latypov, Naimdzhon Malikov provided detailed review of the article. All co-authors reviewed and commented on the final draft. Acknowledgements The authors would like to thank all those including experts, OAT program activists and members of the advisory groups who donated their time and contributed to the development of the assessments’ reports in 4 countries. The information presented in the article on Ukraine would not have been possible without the national consultant Oleksandr Zeziulin who helped with conducting of the assessment in Ukraine in 2020 and Iryna Ivanchuk, Head of viral hepatitis and opioid dependency Department, Public Health Center of the MoH of Ukraine, who contributed to the development of the report on the results of the Ukrainian assessment in 2023. The authors also would like to express their gratitude to Prof. Nick Crofts, Editor-in-Chief of Harm Reduction Journal, for granting the authors with a waiver for this article to be published. Authors' information E-mail addresses of all authors: Raminta Stuikyte [email protected] Ivan Varentsov [email protected] Sergii Dvoriak [email protected] Catherine Cook [email protected] Aleksei Kralko [email protected] Naimdzhon Malikov [email protected] Myroslava Filippovych [email protected] Ala Iatco [email protected] Alisher Latypov [email protected] References World Health Organization (WHO). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence, 2019. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users – 2012 revision. Geneva; World Health Organization, 2012. WHO. Access to Hepatitis C Testing and Treatment For People Who Inject Drugs and People in Prisons — A Global Perspective. Policy Brief; Geneva, WHO, April 2019. WHO. Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations - 2022 update. Geneva; WHO, 2022. World Health Organization Model List of Essential Medicines – 22nd List, 2021. Geneva: World Health Organization; 2021 (WHO/MHP/HPS/EML/2021.02). Harm Reduction International (2022) Global State of Harm Reduction 2022. London: Harm Reduction International. Safranchuk I. Russia in a Reconnecting Eurasia. CSIS, September 30, 2016. Accessed on 17 September 2023 at https://www.csis.org/analysis/russia-reconnecting-eurasia Klyueva A, Tsetsura K. Strategic aspects of Russia’s cultural diplomacy in Europe: Challenges and opportunities of the 21st Century, by Catellani, A., Trench, R. and Zerfass, A., Brussels: PIE Peter Lang, 2015. Golichenko M, Elliott R. Drug laws and policies in four regions of Eurasia. Eastern and Central European and Central Asian Commission on Drug Policy (ECECACD). November 2021. Sarang, A., Stuikyte, R., & Bykov, R. (2007). Implementation of harm reduction in Central and Eastern Europe and Central Asia. International Journal of Drug Policy, 18(2), 129-135. Pates, R, Riley, D (Ed.). Harm Reduction in Substance Use and High-Risk Behaviour: International Policy and Practice. Addiction Press: ISBN: 978-1-405-18297-3, July 2012. Stuikyte, R. (2021). Perception of drugs in Central and Eastern Europe and Central Asia: overhaul needed. Eastern and Central European and Central Asian Commission on Drug Policy (ECECACD). Elovich, R., Drucker, E. On drug treatment and social control: Russian narcology's great leap backwards. Harm Reduct J 5, 23 (2008). https://doi.org/10.1186/1477-7517-5-23 Dvoryak, S. Evaluation of effectiveness of drug treatment programmes in Ukraine. Heroin Addiction and Related Clinical Problems 2004: 6(3): 33-36. World Health Organization. (2004). The practices and context of pharmacotherapy of opioid dependence in central and Eastern Europe (No. WHO/MSD/MSB/04.1). World Health Organization. Latypov A. Opioid substitution therapy in Tajikistan: Another perpetual pilot? Int J Drug Policy. 2010 Sep;21(5):407-10. doi: 10.1016/j.drugpo.2010.01.013. Epub 2010 Feb 24. PMID: 20185288. Country reported OAT coverage for the Global AIDS Monitoring report was taken from the database of the Joint HIV/AIDS Programme on HIV/AIDS (UNAIDS) available at https://aidsinfo.unaids.org, accessed on 14 June 2023 EMCDDA. 2022 Statistical Bulletin, accessed on 14 June 2023 at https://www.emcdda.europa.eu/data/stats2022_en [data for Latvia and Lithuania only as they were absent in the UNAIDS database]. Hrytsenko Y. Fight for life: how Ukraine is fixing medical procurement and serving patients better [Internet]. Open Contracting Partnership. 2021. Accessed on 25 February 2024 at https://www.open-contracting.org/2021/02/22/fight-for-life-how-ukraine-is-fixing-medical-procurement-and-serving-patients-better/ Veljanov, Z. and Fazekas, M. (2023). Efficiency gains from anti-corruption in pharmaceuticals procurement: Analysis of 9 countries across 3 continents. GTI-WP/2023:04, Budapest: Government Transparency Institute. Huffstetler HE, Bandara S, Bharali I, Mcdade KK, Mao W, Guo F, Zhang J, Riviere J, Becker L, Mohamadi M, Rice RL, King Z, Farooqi ZW, Zhang X, Yamey G, Ogbuoji O. The impacts of donor transitions on health systems in middle-income countries: a scoping review. Health Policy and Planning. 2022 Nov;37(9):1188–1202. https://doi.org/10.1093/heapol/czac063. Hirschhorn, L.R., Talbot, J.R., Irwin, A.C. et al. From scaling up to sustainability in HIV: potential lessons for moving forward. Global Health 9, 57 (2013). https://doi.org/10.1186/1744-8603-9-57. Oberth G., Whiteside A. What does sustainability mean in the HIV and AIDS response? African Journal of AIDS Research 2016, 15: 1–9. KFF & UNAIDS (2023). Donor Government Funding for HIV in Low- and Middle-Income Countries in 2022. Accessed on 17 September 2023 at https://files.kff.org/attachment/Report-Donor-Government-Funding-for-HIV-in-Low-and-Middle-Income-Countries-in-2022.pdf The Global Fund (2023). Projected transitions from Global Fund country allocations by 2028: projections by component. February 2023 update. Accessed on 10 December 2023 at: https://www.theglobalfund.org/media/9017/core_projectedtransitionsby2028_list_en.pdf Stuikyte R, Varentsov I, Cook C, Dvoriak S. Measuring sustainability of opioid agonist therapy programs in the context of transition from global fund support. Harm Reduction Journal. 2024 Dec;21(1):1-2. Iatco A. Republic of Moldova: Assessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. Vilnius, Lithuania: Eurasian Harm Reduction Association (EHRA), 2020. Kralko A.A., Republic of Belarus: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding. EHRA, February-April 2020. Dvoryak, S, Zeziulin, A. Украина: Анализ устойчивости программ поддерживающей терапии агонистами опиоидов в контексте перехода от донорской поддержки к национальному финансированию. [in English: Analysis of the sustainability of opioid agonist maintenance therapy programme in the context of transition from donor support to domestic funding]. Kyiv, February-April 2020. Latypov, A. Republic of Tajikistan: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding, EHRA, February-March 2020. Kralko A.A. Republic of Belarus: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, Lithuania, 2023. Malikov N (2023). Tajikistan: Reassessing the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. Iatco A. Republic of Moldova: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. Dvoryak, S, Filippovich, M. Ukraine: reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023 Stuikyte, R et al. Independent Review of the Ukraine’s Transition Plan 2018-2021. PAS Center: Chisinau, Moldova, 2022. Accessed on 01 October 2023 at: https://www.phc.org.ua/sites/default/files/users/user90/Ukraine%20TP%20review_FINAL%202-15_2023_last.pdf National statistical committee of the Republic of Belarus. Statistical bulletin No: 26/170p «Численность населения на 1 января 2023 г. и среднегодовая численность населения за 2022 год по Республике Беларусь в разрезе областей, районов, городов, поселков городского типа» [in Russian. Population as of January 1, 2023 and the average annual population for 2022 in the Republic of Belarus by regions, districts, cities, urban settlements]. Belstat: Minsk, 2023. Accessed on 15 January 2024 at: https://www.belstat.gov.by/ofitsialnaya-statistika/solialnaya-sfera/naselenie-i-migratsiya/naselenie/statisticheskie-izdaniya/index_67489/ State Statistics Service of Ukraine. Demographic situation in 2021. Macroeconomic indicator 12 June 2023. Kyiv, 2023. Accessed on 15 January 2024 at: https://stat.gov.ua/en/publications/demographic-situation-2021. Public Health Center of the MoH of Ukraine Official statistics on the opioid substitution treatment program in Ukraine. Kyiv. 2014-2023. 2023. https://phc.org.ua/kontrol-zakhvoryuvan/zalezhnist-vid-psikhoaktivnikh-rechovin/zamisna-pidtrimuvalna-terapiya-zpt/statistika-zpt Serebryakova L et al. Failure to Fund: The Continued Crisis for Harm Reduction Funding in Low- and Middle-Income Countries. Harm Reduction International: London, 2021. Zhao F, Benedikt C, Ward K. HIV and Allocative Efficiency in Eastern Europe and Central Asia. Tackling the World’s Fastest-Growing HIV Epidemic. World Bank: Washington D.C, July 2020. Holt E. Difficult choices for people with HIV in the Donbas. The Lancet HIV. 2024 Jan 8. Azzopardi-Muscat N, Zapata T, Kluge H. Moving from health workforce crisis to health workforce success: the time to act is now. The Lancet Regional Health–Europe. 2023 Dec 1;35. Additional Declarations Competing interest reported. The manuscript presents the results of the assessment of the OAT sustainability progress in the context of transition from Global Fund support in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine. Ivan Varentsov is coordinating the work of the EECA Regional Platform for Communication and Coordination – the project being hosted by the Eurasian Harm Reduction Association and funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. He has not coordinated in any way the concept or content of the manuscript with the Global Fund staff. Raminta Stuikyte is the Chair of the Global Fund’s Technical Review Panel (i.e. an independent expert group which evaluates all funding requests submitted to the Global Fund). She has not discussed the conception or the development of the article with the Global Fund staff or the Technical Review Panel. Cite Share Download PDF Status: Published Journal Publication published 16 Oct, 2024 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Revision requested 11 May, 2024 Reviews received at journal 11 May, 2024 Reviews received at journal 06 May, 2024 Reviewers agreed at journal 30 Apr, 2024 Reviewers agreed at journal 26 Apr, 2024 Reviewers agreed at journal 11 Mar, 2024 Reviewers invited by journal 09 Mar, 2024 Editor assigned by journal 08 Mar, 2024 Submission checks completed at journal 08 Mar, 2024 First submitted to journal 06 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4021071","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278339462,"identity":"35544dac-09a9-4ba3-a374-a32141f0d962","order_by":0,"name":"Raminta Stuikyte","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYJCCAzDGwQYgwQ9iJRQQ0pIAJNnAWgwYJEH6EgwI2QPVwgjSYgC2FI8W8/bTiYcLf9gxyM/vMTw4s+2PnPH51YkfHhgwyPOLHcCqReZM7obDMxKSGQyO8Rgc3NhmYGx24+1mCaDDDGfOTsCqRYIBqIUngZnBgA2o5WGbQeK2G2c3gLQkGNzGoYX/LUhLPYN8G0RL/eYZZzf/wKtFAmzLYQYGqMMSDPh7t+G3RQJkS9pxHoNjaQUHZ5wzNpxxg3ebRYKBBG6/8Odu/sxjUy0n33x488eeMjl5/v6zm2/+qLCR55fGrgUGeMAkIxvIlARIuBAJ/gAx/wFiVY+CUTAKRsEIAQCszmK1EBN86QAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Raminta","middleName":"","lastName":"Stuikyte","suffix":""},{"id":278339463,"identity":"cef41eb5-e849-4d86-936d-6e8fc38f20a2","order_by":1,"name":"Ivan Varentsov","email":"","orcid":"","institution":"Eurasian Harm Reduction Association (EHRA)","correspondingAuthor":false,"prefix":"","firstName":"Ivan","middleName":"","lastName":"Varentsov","suffix":""},{"id":278339464,"identity":"15015b99-de99-496b-ab84-46a13628e09a","order_by":2,"name":"Sergii Dvoriak","email":"","orcid":"","institution":"Ukrainian Institute of Public Health Policy","correspondingAuthor":false,"prefix":"","firstName":"Sergii","middleName":"","lastName":"Dvoriak","suffix":""},{"id":278339465,"identity":"d2d039cd-d2ad-40b9-ab93-b67a5444c432","order_by":3,"name":"Myroslava Filippovych","email":"","orcid":"","institution":"Ukrainian Institute of Public Health Policy","correspondingAuthor":false,"prefix":"","firstName":"Myroslava","middleName":"","lastName":"Filippovych","suffix":""},{"id":278339466,"identity":"1b194cdc-8c78-4bd5-894b-f3d83edeeb6c","order_by":4,"name":"Aleksei Kralko","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Aleksei","middleName":"","lastName":"Kralko","suffix":""},{"id":278339467,"identity":"809435bc-7d14-4c21-aada-7e46478d4681","order_by":5,"name":"Naimdzhon Malikov","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Naimdzhon","middleName":"","lastName":"Malikov","suffix":""},{"id":278339468,"identity":"bd74f1d4-031a-445e-ac78-13378cb434f1","order_by":6,"name":"Ala Iatco","email":"","orcid":"","institution":"Union for HIV prevention and Harm Reduction","correspondingAuthor":false,"prefix":"","firstName":"Ala","middleName":"","lastName":"Iatco","suffix":""},{"id":278339469,"identity":"d479da57-3f96-4f4a-af41-644960deddb1","order_by":7,"name":"Alisher Latypov","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Alisher","middleName":"","lastName":"Latypov","suffix":""},{"id":278339470,"identity":"d23bad78-fc2d-4b4f-855f-f5b800d2a41f","order_by":8,"name":"Catherine Cook","email":"","orcid":"","institution":"Harm Reduction International","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Cook","suffix":""}],"badges":[],"createdAt":"2024-03-06 13:15:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4021071/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4021071/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-024-01050-6","type":"published","date":"2024-10-16T15:58:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52546053,"identity":"a18b5927-d52f-44e0-b2ea-8af2e58e7971","added_by":"auto","created_at":"2024-03-12 18:44:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23757,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eScale used for measuring dimensions and indicators\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4021071/v1/517fd6b1c2015d7527f6bb9d.png"},{"id":67149111,"identity":"050ed88b-c903-4adf-809e-13e58c6bf047","added_by":"auto","created_at":"2024-10-21 16:12:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":666654,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4021071/v1/c271b9d5-0c38-4b14-b861-c283c2e1f86d.pdf"}],"financialInterests":"Competing interest reported. The manuscript presents the results of the assessment of the OAT sustainability progress in the context of transition from Global Fund support in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine.\n\n-\tIvan Varentsov is coordinating the work of the EECA Regional Platform for Communication and Coordination – the project being hosted by the Eurasian Harm Reduction Association and funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. He has not coordinated in any way the concept or content of the manuscript with the Global Fund staff. \n-\tRaminta Stuikyte is the Chair of the Global Fund’s Technical Review Panel (i.e. an independent expert group which evaluates all funding requests submitted to the Global Fund). She has not discussed the conception or the development of the article with the Global Fund staff or the Technical Review Panel.","formattedTitle":"\u003cp\u003eSustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eOpioid agonist maintenance treatment, or opioid agonist therapy (OAT)[1], combined with psychosocial assistance, is the most effective modality for managing opioid dependence, recommended by the World Health Organization (WHO)\u003csup\u003e1\u003c/sup\u003e. In addition to its function as drug treatment, OAT is part of the core interventions for preventing and managing HIV and the hepatitis C virus among people who use drugs\u003csup\u003e2,3,4\u003c/sup\u003e. Methadone and buprenorphine are part of the WHO Model List of Essential Medicines\u003csup\u003e5\u003c/sup\u003e. Globally, 87 countries implement OAT\u003csup\u003e6\u003c/sup\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Eastern Europe and Central Asia (EECA)[2], OAT remains fragile from the policy, programmatic and financial perspectives. OAT remains unavailable in the Russian Federation, Turkmenistan and Uzbekistan. In addition to legal prohibition of this treatment option, Russia\u0026rsquo;s foreign policy and law enforcement are explicitly against OAT, which is significant given this country\u0026rsquo;s security, economic, and other influence in the region\u003csup\u003e7,8,9\u003c/sup\u003e. In all of the 12 EECA countries with OAT, this care modality was introduced with international donor support, mainly for tackling the HIV epidemic among people who inject heroin and other opioids\u003csup\u003e10,11,12\u003c/sup\u003e. The leaderships of state drug treatment services (called \u0026lsquo;narcology\u0026rsquo; in those countries) and law enforcement has often resisted OAT, arguing that total abstinence should be the main goal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003einstead\u003csup\u003e7,13,14,15\u003c/sup\u003e. Notwithstanding severe HIV epidemics associated with unsafe drug injecting in the EECA, OAT programmes have faced the challenge of being a \u0026lsquo;perpetual pilot project\u0026rsquo;\u003csup\u003e16\u003c/sup\u003e, i.e. being given the status of a pilot over multiple years without systemic scale-up and/or change in status. Currently, only Estonia, Georgia, Latvia and Lithuania fully fund this drug care modality from domestic public resources. The scale of, and access to, OAT remains a concern. According to the latest available data in 2023\u003csup\u003e17,18\u003c/sup\u003e, just one EECA country, Georgia, has achieved coverage at the WHO-recommended medium range. Furthermore, donor-funded HIV operations often involve parallel systems and arrangements for procurement and the supply of health products; payments and training of staff; health information; and financing. While, in certain instances, designed and introduced under justifiable circumstances, such as widespread corruption in national health sector\u003csup\u003e19,20\u003c/sup\u003e, those parallel arrangements are not sustainable and can lead to poor transition without integration into domestic systems and domestic capacity building completed prior to donor phase out\u003csup\u003e21\u003c/sup\u003e. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSustainability of health responses dependent on donor funding is a major concern, especially in the HIV field, where international support is flatlining\u003csup\u003e22,23,24\u003c/sup\u003e. The Global Fund, the major international OAT funder in the EECA region, expects a focus on sustainability and transition preparedness from all lower-middle income countries with a lower disease burden and upper-middle-income countries, including all those EECA countries eligible for Global Fund\u0026rsquo;s HIV funding. This focus should include enhanced transition planning, increased focus on sustainability of interventions for HIV among key and vulnerable populations and accelerated co-financing\u003csup\u003e25\u003c/sup\u003e. Therefore, a reasonable assessment of the OAT status in the EECA is timely to identify trends, risk factors and transition preparedness in the face of reduced international support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e[1] This treatment is known under different names in scientific literature, country policy documents and among practitioners including opioid substitution therapy and medically assisted therapy; however, because of stigma and politicisation attached to the first name, and the inaccurate distinction from other approaches in the second, this article uses the name of OAT.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"ftn2\"\u003e\n \u003cp\u003e[2] For the purposes of this article, the region of Eastern Europe and Central Asia refers to the 15 states that (re)emerged after the collapse of the Soviet Union in the 1990s and includes Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan.\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThe purpose of the study was to assess the progress and risk areas of building sustainability of OAT programmes in 4 EECA countries (Belarus, Republic of Moldova, Tajikistan and Ukraine) in the context of transition from Global Fund financial support to public funding and systems. Based on the results, the study aimed to develop recommendations for national authorities, OAT managers, advocates, international partners and donors, like the Global Fund, on maintaining and expanding OAT programmes in the new environment. The OAT sustainability assessment in these 4 countries was conducted in 2020 and then repeated during 2022-2023 in order to monitor the changes in sustainability over time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInstrument for measuring OAT sustainability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study utilised an OAT-specific instrument for measuring the degree of, and opportunities for, sustainability of OAT. The Eurasian Harm Reduction Association (EHRA) developed and supported the testing of this instrument during 2019-2020, as described in a separate article\u003csup\u003e26\u003c/sup\u003e.\u0026nbsp;The instrument is applicable for the implementation at the national level. It measures three dimensions of programmatic, financial and other aspects of sustainability: Policy \u0026amp; Governance; Finance \u0026amp; Resources; and Services. Each dimension is measured through 2-4 indicators that are composites of benchmarks. Dimensions and corresponding indicators in each dimension are calculated using a 6-rank scale as shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In addition to measuring dimensions and indicators, the instrument requires the compilation of qualitative and other quantitative data to analyse trends, challenges and opportunities for the improved sustainability of OAT.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNational assessments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;To gather inputs for the regional study, EHRA commissioned and led the national assessments by implementing the instrument for measuring OAT sustainability. The country selection prioritised the three countries where the instrument was piloted during 2019-2020. Moldova became the fourth country selected due to significant advocacy opportunities. Each in-country assessment in 2020 and re-assessment during 2022-2023 were conducted by a national consultant selected through a competitive process. Ukraine was an exception as its lead expert was part of the advisory body that supported the development of the instrument. The national consultant was supported by a country-specific multi-stakeholder Advisory Group in all assessments and re-assessments, except Ukraine in 2023. In all countries, national results validation involved a national workshop and/or a review of the report by national stakeholders. EHRA provided technical support for the in-country assessment and facilitated the discussion of the results with national stakeholders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Each national assessment conducted a desk review of legal, policy, clinical and programmatic data, followed by key informant interviews and focus groups with OAT clients to triangulate the data and, where needed, an expert assessment. Data inquiries were placed with various institutions and management organisations to address data gaps in the public domain. In total, across the 4 countries and in the two time periods, the assessments reviewed 363 sources, conducted 83 interviews with key informants and 13 focus groups with OAT clients, as detailed in \u003cem\u003eTable 1\u003c/em\u003e. In the case of Ukraine\u0026rsquo;s assessment during 2022-2023, two data points were collected for most data-related indicators \u0026ndash; one for the status before Russia\u0026rsquo;s full-scale invasion in Ukraine in February 2022 and other at the end of 2022; however, the national consultants that led the scoring of OAT sustainability based their findings on the most recent data available which, in most cases, was the status after the full-scale war had started. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1710236846.png\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompiling results for the regional study\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe compilation of the regional results from all the country assessments and re-assessments relied on the 8 national reports that underwent validation. Therefore, this manuscript did not refer to the primary sources of information used by the country assessments. Instead, it used secondary sources, i.e. the eight validated national assessment reports. Additionally, EHRA archived files with primary and secondary data and analysis to ensure availability and transferability of all scoring and qualitative information over time. This archiving practice was particularly helpful in one country (Tajikistan) where two different consultants conducted the assessment in 2020 and the re-assessment during 2022-2023. The country reports are available online\u003csup\u003e27,28,29,30,31,32,33,34\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll 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\u0026rsquo;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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: OAT sustainability across the three dimensions measured in the four countries in 2020 \u0026amp; 2022-2023.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.08411214953271%\" valign=\"top\"\u003e\n \u003cp\u003eSustainability dimension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.037383177570092%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eA. Policy \u0026amp; Governance\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eB. Finance \u0026amp; Resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eC. Services\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.104524180967239%\" valign=\"top\"\u003e\n \u003cp\u003eYears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.104524180967239%\" valign=\"top\"\u003e\n \u003cp\u003eBelarus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.104524180967239%\" valign=\"top\"\u003e\n \u003cp\u003eMoldova\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.104524180967239%\" valign=\"top\"\u003e\n \u003cp\u003eTajikistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.104524180967239%\" valign=\"top\"\u003e\n \u003cp\u003eUkraine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.260530421216849%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.820592823712948%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.664586583463338%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAcross the three dimensions, there is a great diversity among the countries, as shown in \u003cem\u003eTable 2\u003c/em\u003e. In 2022, Belarus and Moldova achieved the highest scoring of substantial sustainability in the dimension of \u0026lsquo;\u003cem\u003eFinance \u0026amp; Resources\u0026rsquo;\u003c/em\u003e, while Ukraine was rated best, with a substantial degree of sustainability for \u0026lsquo;\u003cem\u003ePolicy \u0026amp; Governance\u0026rsquo;\u003c/em\u003e and \u0026lsquo;\u003cem\u003eServices\u0026rsquo;\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eIn 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 \u0026lsquo;\u003cem\u003eFinance \u0026amp; Resources\u0026rsquo;\u003c/em\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eDimension of \u0026lsquo;Policy \u0026amp; Governance\u0026rsquo;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe dimension of \u0026lsquo;\u003cem\u003ePolicy \u0026amp; Governance\u0026rsquo;\u003c/em\u003e comprises two equally weighted indicators: \u0026lsquo;\u003cem\u003ePolitical commitment\u0026rsquo;\u003c/em\u003e and \u0026lsquo;\u003cem\u003eManagement of transition from donor to domestic funding\u0026rsquo;\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3: Scoring of indicators for \u0026lsquo;Policy \u0026amp; Governance\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"538\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.180633147113593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIndicator\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.87150837988827%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePolitical commitment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.947858472998135%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eManagement of transition from donor to domestic funding\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.180633147113593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eYears\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50465549348231%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.58100558659218%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.180633147113593%\" valign=\"top\"\u003e\n \u003cp\u003eBelarus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50465549348231%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.58100558659218%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.180633147113593%\" valign=\"top\"\u003e\n \u003cp\u003eMoldova\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50465549348231%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.58100558659218%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.180633147113593%\" valign=\"top\"\u003e\n \u003cp\u003eTajikistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50465549348231%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.58100558659218%\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk (23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.180633147113593%\" valign=\"top\"\u003e\n \u003cp\u003eUkraine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50465549348231%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003cp\u003e(77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.58100558659218%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.366852886405958%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003cp\u003e(75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFor the indicator of \u0026lsquo;\u003cem\u003ePolitical commitment\u0026rsquo;\u003c/em\u003e, 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 \u0026lsquo;\u003cem\u003ePolitical commitment\u0026rsquo;\u003c/em\u003e 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\u0026rsquo;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\u0026rsquo;s full-scale invasion of Ukraine that started in 2022.\u003c/p\u003e\n\u003cp\u003eIn 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.\u003c/p\u003e\n\u003cp\u003eBased on the analysis of the indicator of \u0026lsquo;\u003cem\u003eManagement of Transition from Donor to Domestic Funding\u0026rsquo;,\u003c/em\u003e 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 services\u003csup\u003e35\u003c/sup\u003e. 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eDimension of \u0026lsquo;Finance \u0026amp; Resources\u0026rsquo;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFour indicators \u0026ndash; \u0026lsquo;\u003cem\u003eMedications\u0026rsquo;, \u0026lsquo;Financial resources\u0026rsquo;, \u0026lsquo;Human resources\u0026rsquo;\u003c/em\u003e and \u0026lsquo;\u003cem\u003eEvidence \u0026amp; information systems\u0026rsquo;\u003c/em\u003e \u0026ndash; comprise the dimension of \u0026lsquo;\u003cem\u003eFinance \u0026amp; Resources\u0026rsquo;\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4: Scoring of indicators for \u0026lsquo;Finance \u0026amp; Resources\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"632\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.885895404120443%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIndicator\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.02852614896989%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMedications\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.02852614896989%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFinancial resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.02852614896989%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHuman resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.02852614896989%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEvidence \u0026amp; information systems\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.811023622047244%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eYears\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022/23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.811023622047244%\" valign=\"top\"\u003e\n \u003cp\u003eBelarus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial (74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003cp\u003e(78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003cp\u003e(97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003cp\u003e(71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.811023622047244%\" valign=\"top\"\u003e\n \u003cp\u003eMoldova\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial (77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eHigh (92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eHigh (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.811023622047244%\" valign=\"top\"\u003e\n \u003cp\u003eTajikistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk\u003c/p\u003e\n \u003cp\u003e(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk (49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.811023622047244%\" valign=\"top\"\u003e\n \u003cp\u003eUkraine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk (49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.023622047244094%\" valign=\"top\"\u003e\n \u003cp\u003eHigh (92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe \u0026lsquo;\u003cem\u003eMedications\u0026rsquo;\u003c/em\u003e 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\u0026rsquo;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\u0026rsquo;s assessment reported challenges with the supply chain \u0026ndash; 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.\u003c/p\u003e\n\u003cp\u003eIn terms of \u0026lsquo;\u003cem\u003eFinancial Resources\u0026rsquo;\u003c/em\u003e, 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, \u0026lsquo;People\u0026apos;s Health and Demographic Security in the Republic of Belarus\u0026rsquo; for 2016\u0026ndash;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 \u0026ndash; Belarus and Moldova \u0026ndash; 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 \u003cem\u003eTable 5\u003c/em\u003e. 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 OAT\u003csup\u003e41\u003c/sup\u003e. 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\u0026rsquo;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\u0026rsquo;s income and economy, not only moving the funding for medicines back to donor support but also resulting in decreased predictability of the state\u0026rsquo;s economic prospects at large and its ability to fund OAT. Among the four countries, Tajikistan scored lowest for the indicator of \u0026lsquo;\u003cem\u003eFinancial resources\u0026rsquo;\u003c/em\u003e 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 \u0026lsquo;Implementation Plan of the National Programme to Combat the HIV/AIDS Epidemic in the Republic of Tajikistan for 2021\u0026ndash;2025\u0026rsquo;. 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.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1710237145.png\"\u003e\u003c/p\u003e\n\u003cp\u003eIn 2022, the \u0026lsquo;\u003cem\u003eHuman resource\u0026rsquo;\u003c/em\u003e 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\u0026rsquo;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\u0026rsquo; 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 \u0026ndash; linked to results \u0026ndash; 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.\u003c/p\u003e\n\u003cp\u003eIn both 2020 and 2022, Ukraine made particularly substantial progress in building their \u0026lsquo;\u003cem\u003eEvidence and Information Systems\u0026rsquo;,\u003c/em\u003e including open-data M\u0026amp;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\u0026rsquo;s rating of the country decreased due to the impact of COVID-19 on research involving clients. Moldova remained stable for the indicator of \u0026lsquo;\u003cem\u003eEvidence and Information Systems\u0026rsquo;\u003c/em\u003e 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\u0026rsquo;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.\u003c/p\u003e\n\u003cp\u003eAcross the four countries, the indicator \u0026lsquo;\u003cem\u003eEvidence and Information System\u0026rsquo;s\u0026rsquo;\u0026nbsp;\u003c/em\u003egenerally continues to depend on international funding and technical support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eDimension of \u0026lsquo;Services\u0026rsquo;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the \u0026lsquo;\u003cem\u003eService\u0026rsquo;\u003c/em\u003e dimension, among the three indicators, the highest degree of sustainability is recorded for \u0026lsquo;\u003cem\u003eAccessibility\u0026rsquo;,\u0026nbsp;\u003c/em\u003eclosely followed by\u003cem\u003e\u0026nbsp;\u0026lsquo;Quality \u0026amp; integration\u0026rsquo;\u003c/em\u003e, with\u003cem\u003e\u0026nbsp;\u0026lsquo;Availability \u0026amp; coverage\u0026rsquo;\u0026nbsp;\u003c/em\u003econtinuing to lag, as shown in \u003cem\u003eTable 6.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 6: Scoring of indicators for \u0026lsquo;Services\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.01923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIndicator\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.28846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAvailability \u0026amp; coverage\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAccessibility\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eQuality \u0026amp; integration\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.038523274478331%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eYears\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53290529695024%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.038523274478331%\" valign=\"top\"\u003e\n \u003cp\u003eBelarus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53290529695024%\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk\u003c/p\u003e\n \u003cp\u003e(8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk\u003c/p\u003e\n \u003cp\u003e(17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate (62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003cp\u003e(71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.038523274478331%\" valign=\"top\"\u003e\n \u003cp\u003eMoldova\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53290529695024%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk\u003c/p\u003e\n \u003cp\u003e(37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003cp\u003e(83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.038523274478331%\" valign=\"top\"\u003e\n \u003cp\u003eTajikistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53290529695024%\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAt high risk (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.038523274478331%\" valign=\"top\"\u003e\n \u003cp\u003eUkraine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53290529695024%\" valign=\"top\"\u003e\n \u003cp\u003eAt moderate-to-high risk (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eModerate (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSubstantial\u003c/p\u003e\n \u003cp\u003e(70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e(69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eHigh\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAdditionally, \u003cem\u003eTable 7\u003c/em\u003e provides an overview of several key benchmarks across the \u003cem\u003eService\u003c/em\u003e dimension.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 7: Selected OAT markers for the \u0026lsquo;Service\u0026rsquo; dimension (latest data reported in the 2022-2023 national assessments)\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBelarus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMoldova\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTajikistan\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUkraine\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.2 million (2022)\u003csup\u003e36\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2 million\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;10 million (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.2 million[5] (2022)\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of people with opioid dependence in state drug treatment system or registered by the system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,579 (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,575 (all psychoactive substances) (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,749\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(December 31, 2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEstimated number of people who use opioids (alternatively, estimated number of people who inject drugs)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73,800 and 87,000 people (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12,920 (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22,208 (2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e270,800 (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedicines used for OAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethadone, buprenorphine\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethadone, buprenorphine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethadone (liquid)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethadone, buprenorphine, start of the use of long-acting buprenorphine in January 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAvailability and coverage\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCoverage of the estimated number of people with opioid dependence or people injecting drugs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.5% (2022)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.4%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[7.3% in February 2022, at the beginning of the Russian invasion]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of OAT clients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e707 (end 2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e590 (September 2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e614 (December 2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27,432 (December 2022) [20,331 in February 2022, at the beginning of the Russian invasion]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of OAT sites (excluding penitentiary system)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (end 2021))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 sites in 10 cities (September 2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 sites (December 2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e207 sites (end of 2022)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[224 sites in February 2022, at the beginning of the Russian invasion]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePercent of administrative units with OAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29%\u003c/p\u003e\n \u003cp\u003e(10 out of 34 administrative units), excluding non-government-controlled area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%, excluding the temporarily occupied territories\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe share of clients receiving OAT in state specialised drug treatment or mental health institutions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTake-home dosages upon clinical prescription\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes (provided to around 90% of all clients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAvailability in primary care and hospitals, licensed private sector and NGOs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospitals, primary care, private sector (around 27% of all clients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAvailability in penitentiary settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-trial detention only upon special approval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-trial detention, 13 correctional facilities including for females\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 penitentiary institutions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-trial detention; 7 penitentiary institutions (including one for females and one for juvenile offenders)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eQuality and integration\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRecommended dosages in clinical guidelines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMinimum 60mg for methadone and 12mg for buprenorphine.\u003c/p\u003e\n \u003cp\u003eNo restrictions on maximum dosage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethadone: 60-120mg; Buprenorphine: \u0026nbsp;16mg\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMinimum 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\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMinimum 80mg for methadone and 8mg for buprenorphine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAverage dosage of methadone, buprenorphine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003eMethadone\u003c/u\u003e: \u0026gt;=60mg\u003c/p\u003e\n \u003cp\u003e\u003cu\u003eBuprenorphine\u003c/u\u003e: \u0026gt;=12mg\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003eMethadone\u003c/u\u003e: \u0026gt;=50mg by 87% clients in one site and 76% of clients in a study in 2021;\u003c/p\u003e\n \u003cp\u003e\u003cu\u003eBuprenorphine\u003c/u\u003e: 8mg in one site and a study in 2021.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethadone: \u0026ge;60mg received by 46% (data from 6 out of 13 sites)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003eMethadone\u003c/u\u003e \u0026gt;=80mg in 86% of medical facilities;\u003c/p\u003e\n \u003cp\u003e\u003cu\u003eBuprenorphine\u003c/u\u003e: \u0026gt;=8 mg/day or more in 93% of facilities.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRetention (% of clients on therapy for 6 months or longer)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65%-100% in 2022 (data from 12 out of 13 sites)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u0026ndash;80% in 2022\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of HIV or TB specialised services that provide OAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (and 139 multidisciplinary hospitals)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShare of OAT sites with integrated care for HIV/TB/HCV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27%\u003c/p\u003e\n \u003cp\u003eOnly 3 sites in civil sector (out of 11) integrated into a comprehensive framework and/or interacting with other services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAll state funded sites are expected to provide linkages to other services;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53% of OAT clients reported the availability of additional services at OAT sites\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003eFor the indicator \u0026lsquo;\u003cem\u003eAvailability \u0026amp; coverage\u0026rsquo;\u003c/em\u003e, 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\u0026rsquo;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\u0026rsquo;s armed forces\u003csup\u003e38\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eMoldova started allowing self-administration and video-observed administration of OAT in 2020 during the COVID-19 pandemic\u0026rsquo;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, \u0026lsquo;On medical care for clients with dependence on narcotic drugs of the opium group\u0026rsquo;. 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.\u003c/p\u003e\n \u003cp\u003eIn 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.\u003c/p\u003e\n \u003cp\u003eThe \u003cem\u003eAccessibility\u003c/em\u003e indicator\u0026nbsp;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.\u003c/p\u003e\n \u003cp\u003eEach country reported both good practices and challenges under the indicator of \u003cem\u003eQuality and integration\u0026nbsp;\u003c/em\u003epertaining to\u003cem\u003e\u0026nbsp;\u0026lsquo;Service\u0026rsquo;\u0026nbsp;\u003c/em\u003edimension. 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 \u0026ndash; all set at 60mg for methadone, except for 80mg in Ukraine. However, for buprenorphine, Ukraine\u0026rsquo;s OAT programme, which is the most experienced with this substance among the four countries, has the lowest minimum dosage (8mg), as detailed in \u003cem\u003eTable 7\u003c/em\u003e. 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.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAreas of progress and challenges\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNone 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: \u003cem\u003eMedicines\u003c/em\u003e (Belarus, Moldova); \u003cem\u003eFinancial resources\u003c/em\u003e (Belarus, Moldova); \u003cem\u003eEvidence and information systems\u003c/em\u003e (Ukraine); \u003cem\u003eService Accessibility\u003c/em\u003e (Belarus); and \u003cem\u003eService integration \u0026amp; quality\u003c/em\u003e (Ukraine). Overall, the highest improvement between 2020 and 2022 was seen for \u003cem\u003eAvailability \u0026amp; coverage\u003c/em\u003e, \u003cem\u003eFinancial resources\u003c/em\u003e, \u003cem\u003eService quality \u0026amp; integration\u003c/em\u003e and \u003cem\u003eService accessibility\u003c/em\u003e. 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.\u003c/p\u003e\n \u003cp\u003eThe greatest risks across the countries, in particular in Belarus and Tajikistan, were recorded for \u003cem\u003eService Availability and coverage\u003c/em\u003e 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\u0026rsquo;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 \u003cem\u003eHuman resources\u003c/em\u003e indicator is affecting the OAT sustainability.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e[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\u0026rsquo;s preliminary estimates, in 2022, Ukraine\u0026rsquo;s gross national income per capita was nearly 4 times higher than in Tajikistan.\u003cbr\u003e[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\u0026rsquo;s control and has been governed by a Russia-backed self-proclaimed and unrecognised government.\u003c/p\u003e\n \u003cp\u003e[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.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOAT remains at risk during the process of transition from donor support to domestic funding in Eastern Europe and Central Asia. Globally, in 2019, only 9% of the UNAIDS-estimated funding required for OAT and other harm reduction interventions was available in low- and middle-income countries, coming in equal portions from domestic public resources and donors\u003csup\u003e39\u003c/sup\u003e. As the World Bank classification of income status remains the cornerstone of eligibility and the funding allocation formula for donors such as the Global Fund, countries of the EECA region, as well as other middle-income countries, are advancing closer to transition and ineligibility in the continuum of donor support.\u003c/p\u003e\n\u003cp\u003eWhile the four analysed countries rolled out OAT programme at similar times, their development pace and approach \u0026nbsp;vary and are country specific. OAT is increasingly recognised as part of the core care, with state funding invested in all the middle-income countries analysed; however, there is limited will to scale it up and to address the real need. All countries have clinical guidelines and clinical leadership on OAT from the drug treatment system. However, the political support and the accountability mechanisms for scale-up and domestic investments continue to draw mainly from the national HIV strategies, programmes and budgets (and not the drug strategies and budgets).\u003c/p\u003e\n\u003cp\u003eThis assessment highlights both positive and negative elements of the reforms. For example, in Ukraine, the transition to domestic funding and changes to the payment methods in 2020 meant that the previous generous financial incentives to providers were replaced by less economically attractive fees for service managers, and some smaller sites discontinued services; nevertheless, the overall number of clients has increased. The health financing and organisational reform in Ukraine had led to significant changes in narcological care and enabled the greater integration of OAT outside of specialised settings, probably making Ukraine the leader in decentralisation and integration in the region. Critical factors for utilising this broader health reform for OAT progress were seen in having a clearly-mandated institution that was responsible for OAT development and in the presence of the high-profile, open-minded, multisectoral group that supported that development politically and technically. On the flipside, in Belarus, Moldova and Tajikistan, the health system strategies aim to strengthen primary care and UHC; however, they are yet to break the barriers for OAT expansion through general practitioners and other non-narcological care.\u003c/p\u003e\n\u003cp\u003eMoreover, across the four - and other - countries in the EECA region, the national HIV and TB programmes have been subject to regular systemic programmatic reviews by WHO at the request of ministries of health. This scrutiny of the national HIV programmes aims to improve their value for money, including their efficiency\u003csup\u003e40\u003c/sup\u003e. In contrast, the narcology system - where management of opioid dependence, including OAT, are just one of the functions - has not been subject to similar reviews of their effectiveness and efficiency for realistic public health goals and for setting roadmaps for their reform.\u003c/p\u003e\n\u003cp\u003eThe territories in active war or frozen conflicts, like those in Ukraine and Moldova, require a different timeline for donor exit and collective solutions and, in the case of OAT, might not be possible without broader geopolitical changes. For example, since 2014, when self-proclaimed Russia-backed separatists took power in Eastern Ukraine, access to antiretroviral therapy (ART) and TB treatments depended on international humanitarian support. Once the humanitarian channel became unworkable and stocks ran out, in 2023, the Russian Federation started funding ART in Donetsk, reportedly subject to accepting Russian citizenship\u003csup\u003e41\u003c/sup\u003e. Moreover, OAT is unavailable in the non-government-controlled areas of Moldova and temporary occupied territories of Ukraine where Russia-installed de facto authorities replicated Russia\u0026rsquo;s anti-OAT stance.\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic shifted the focus of many health programmes to the emergency response; therefore, it somewhat weakened the attention to donor transition-related planning, at least in some settings. Nevertheless, evidence from the three countries showed the pandemic\u0026rsquo;s progressive influence on health sector\u0026rsquo;s emergency response preparedness also allowed for the decentralisation of OAT provision, including greater self-care, in alignment with WHO recommendations.\u003c/p\u003e\n\u003cp\u003eTransition planning and management of the national HIV programmes have had a positive role in increasing the sustainability of OAT, by presenting a vision and plan for sustaining various elements, particularly financial resources, of OAT. Furthermore, the multi-sectoral approach of HIV governance and transition can facilitate a dialogue across different ministries, including the ministries of health, finance and interior.\u003c/p\u003e\n\u003cp\u003eThis study outlines areas for further advocacy and support for greater self-reliance of OAT, some less articulated in the national programme documents. The study highlights the human resource challenges. There is a growing recognition of, and attention to, the need to address the general human resource crises in the health sector across Europe\u003csup\u003e42\u003c/sup\u003e; however, this system building block has been understated in the sustainability and transition planning, so far, and should receive greater prioritisation in the future, including for OAT sustainability building.\u003c/p\u003e\n\u003cp\u003eThe inclusion of critical stakeholders in the assessments, either in the country-specific advisory groups and/or in the validation of reports, increased ownership and use of reports and the increased attention to sustainability risks at the country level, as highlighted in the article dedicated to the instrument which was used for this study for measuring sustainability of OAT\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eLimitations\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite the emphasis on increasing objectivity, the country assessments had a degree of subjectivity and adaptation to various health systems and political contexts in their quantitative analyses. For example, Moldova\u0026rsquo;s 2022 reassessment narrowed the review of the indicator,\u003cem\u003e\u0026nbsp;\u0026lsquo;Management of transition from donor to domestic funding\u0026rsquo;,\u003c/em\u003e to one aspect of OAT, that of psychosocial support which remains funded by donors, while other core services and medication provision have been funded by the government for several years. In Belarus, Tajikistan and, to some extent, Moldova, desk reviews identified only a limited amount of public information; information was acquired through experts with access to internal databases, or through inquiries for information, or had to rely on expert opinions. This significantly impacted the speed of respective assessments.\u003c/p\u003e\n\u003cp\u003eWhile the national assessments did not seek ethical committee approvals, the instrument development involved a multistakeholder group including a representative of the International Network of People who Use Drugs (INPUD) and WHO. Seven out of 8 assessments included OAT expert clients to inform the design, implementation and validation of the reports. In Tajikistan, in 2022, the assessment and its format, methodology and tools were formally agreed upon with the Ministry of Health and Social Protection of the Population (MoHSP) in addition to the advisory group. In 2023, Ukraine\u0026rsquo;s re-assessment did not involve an advisory group; however, the results were summed up with partners and the report went through a review process including by the Public Health Centre under the Ministry of Health and the Global Fund.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe client perspectives have been included only to a limited extent. The Belarus assessments did not involve a focus group with a broader number of OAT clients; however, the 2022 re-assessment increased the number of OAT clients among key informants to shine a light on the satisfaction with quality and on barriers and opportunities for increased uptake. The limited number of focus groups in all countries meant that only clients from larger cities and sites were directly involved. Tajikistan was an exception and managed to engage direct views from smaller sites through a higher number and geography of focus groups.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOAT sustainability in the four countries remains at risk and requires further planning and management.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The resilience of the OAT programmes, and ability to scale up, depend on multiple factors. Political will and continued funding are some of them. Ukraine exemplifies the ability to address both previously documented challenges, such as rigid stock management and high specialisation of service providers as well as new obstacles related to the country being at war and enduring a difficult economic period, demonstrating that building sustainability is not only about securing domestic funding. The country included OAT in its transition planning and health reforms which enabled it to secure state guarantees for this care, a true top leadership commitment to OAT and to the integration and decentralisation of this method for greater access, scale and people-centredness. The other three countries also showed important practices and lessons for building OAT sustainability which were closely interlinked with the uptake of the WHO and UN recommendations for these programmes.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There is a need for an increased focus on programmatic elements of OAT sustainability - the resource inputs and service attractiveness across the four countries. The study offers a review of those needs and suggests pathways going forward. Some of the follow-up steps could benefit from cooperation and synergies with teams working on sustainability in the HIV and TB fields (such as medication procurement, UHC packages, multidisciplinary care and integration in primary settings). The collaborative approach to the assessment, with the engagement of key stakeholders responsible for OAT through an advisory group, has been proven to support greater follow-up and ownership which might affect the ability of a stronger articulation of recommendations. As these countries undergo major transformations and donor transition, similar and potentially simplified assessments may need to be planned in the countries. Finally, while COVID-19 had greatly impacted national health systems, the pandemic also enabled the adoption of measures to ensure greater accessibility of services. This could be seen as an opportunity for continuing the dialogue for more accessible, sustainably resourced and politically backed OAT.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIDS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acquired Immunodeficiency Syndrome\u003c/p\u003e\n\u003cp\u003eART\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;antiretroviral therapy\u003c/p\u003e\n\u003cp\u003eEECA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Eastern Europe and Central Asia\u003c/p\u003e\n\u003cp\u003eEHRA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Eurasian Harm Reduction Association\u003c/p\u003e\n\u003cp\u003eGDP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Gross Domestic Product\u003c/p\u003e\n\u003cp\u003eGlobal Fund\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria\u003c/p\u003e\n\u003cp\u003eHIV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003eINPUD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Network of People who Use Drugs\u003c/p\u003e\n\u003cp\u003eMoHSP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ministry of Health and Social Protection of the Population\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNGO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Non-Governmental Organisation\u003c/p\u003e\n\u003cp\u003eOAT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Opioid Agonist Therapy\u003c/p\u003e\n\u003cp\u003eTB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tuberculosis\u003c/p\u003e\n\u003cp\u003eUHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Universal Health Coverage\u003c/p\u003e\n\u003cp\u003eUNDP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United Nations Development Programme\u003c/p\u003e\n\u003cp\u003eUNODC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United Nations Office on Drugs and Crime\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable as the manuscript does not report on or involve the use of any animal or human data or tissue. Seven out of 8 national level assessments which results are being summarized in the maniscript involved a multistakeholder advisory groups (which included OAT expert clients) to inform the design, implementation and validation of the assessment reports. In 2023, Ukraine\u0026rsquo;s re-assessment did not involve an advisory group; however, the results were summed up with partners and the report went through a review process including by the Public Health Centre under the Ministry of Health and the Global Fund. All experts being interviewed for the assessment purposes and participated in focus groups in 4 countries signed informed consent forms. \u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable as the manuscript doesn\u0026rsquo;t contain any individual person\u0026rsquo;s data in any form.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe methodology and instrument used to conduct the assessments which results are being described in this manuscript are available online at: https://eecaplatform.org/en/oat-a-guide-for-assessment-in-the-context-of-donor-transition/ \u003c/p\u003e\n\u003cp\u003eData supporting the assessments\u0026rsquo; results reported in the article can be found in:\u003c/p\u003e\n\u003cp\u003eIatco A. Republic of Moldova: Assessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. Vilnius, Lithuania: Eurasian Harm Reduction Association (EHRA), 2020. https://eecaplatform.org/en/ptao-v-moldove/ \u003c/p\u003e\n\u003cp\u003eKralko A.A., Republic of Belarus: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding. EHRA, February-April 2020. https://eecaplatform.org/en/oat-in-belarus/ \u003c/p\u003e\n\u003cp\u003eDvoryak, S, Zeziulin, A. Украина: Анализ устойчивости программ поддерживающей терапии агонистами опиоидов в контексте перехода от донорской поддержки к национальному финансированию. [in English: Analysis of the sustainability of opioid agonist maintenance therapy programme in the context of transition from donor support to domestic funding]. Kyiv, February-April 2020. https://eecaplatform.org/ptao-v-ukraine/ \u003c/p\u003e\n\u003cp\u003eLatypov, A. Republic of Tajikistan: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding, EHRA, February-March 2020. https://eecaplatform.org/en/oat-programme-in-tajikistan/ \u003c/p\u003e\n\u003cp\u003eKralko A.A. Republic of Belarus: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, Lithuania, 2023. https://eecaplatform.org/en/oat-reassessment-belarus/ \u003c/p\u003e\n\u003cp\u003eMalikov N (2023). Tajikistan: Reassessing the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. https://eecaplatform.org/en/oat-reassessment-tajikistan/ \u003c/p\u003e\n\u003cp\u003eIatco A. Republic of Moldova: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. https://eecaplatform.org/en/oat-reassessment-moldova/ \u003c/p\u003e\n\u003cp\u003eDvoryak, S, Filippovich, M. Ukraine: reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023 https://eecaplatform.org/en/oat-reassessment-ukraine/ \u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eNone. \u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eUnited Nations Population Fund (UNFPA) and the Technical Support Mechanism of the Joint United Nations Programme on HIV/AIDS (UNAIDS) funded the development of the methodology and instrument used to conduct the assessments which results are described in the article.\u003c/p\u003e\n\u003cp\u003eThe sustainability assessment of the OAT programme in Belarus, Republic of Moldova and Tajikistan in 2020 were implemented with funding provided through the technical support mechanism (TSM) of the Joint United Nations Programme on HIV/AIDS (UNAIDS).\u003c/p\u003e\n\u003cp\u003eThe sustainability assessment of the OAT programme in Ukraine in 2020 was implemented with financial support provided by the International Renaissance Foundation.\u003c/p\u003e\n\u003cp\u003e2023 assessment reports were prepared by Eurasian Harm Reduction Association and published as part of the regional project, \u0026apos;Sustainability of services for key populations in the region of Eastern Europe and Central Asia\u0026apos; (SoS_project 2.0), implemented by a consortium of organisations led by the Alliance for Public Health in partnership with the charitable organization \u0026apos;100% Life\u0026apos;, with financial support from the Global Fund.\u003c/p\u003e\n\u003cp\u003eThe corresponding author received partial support for drafting the article from the Global Fund-financed project \u0026lsquo;EECA Regional Platform for Communication and Coordination\u0026rsquo; through Eurasian Harm Reduction Association.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAll authors discussed the concept and approach to the article. Raminta Stuikyte produced the first draft of the article. Ala Iatco, Myroslava Filippovych, Naimdzhon Malikov, Aleksei Kralko reviewed data cited and its interpretation for the corresponding countries. Ivan Varentsov, Alisher Latypov, Naimdzhon Malikov provided detailed review of the article. All co-authors reviewed and commented on the final draft. \u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all those including experts, OAT program activists and members of the advisory groups who donated their time and contributed to the development of the assessments\u0026rsquo; reports in 4 countries. \u003c/p\u003e\n\u003cp\u003eThe information presented in the article on Ukraine would not have been possible without the national consultant Oleksandr Zeziulin who helped with conducting of the assessment in Ukraine in 2020 and Iryna Ivanchuk, Head of viral hepatitis and opioid dependency Department, Public Health Center of the MoH of Ukraine, who contributed to the development of the report on the results of the Ukrainian assessment in 2023. \u003c/p\u003e\n\u003cp\u003eThe authors also would like to express their gratitude to Prof. Nick Crofts, Editor-in-Chief of Harm Reduction Journal, for granting the authors with a waiver for this article to be published. \u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information \u003c/p\u003e\n\u003cp\u003eE-mail addresses of all authors:\u003c/p\u003e\n\u003cp\u003eRaminta Stuikyte [email protected]\u003c/p\u003e\n\u003cp\u003eIvan Varentsov [email protected]\u003c/p\u003e\n\u003cp\u003eSergii Dvoriak [email protected] \u003c/p\u003e\n\u003cp\u003eCatherine Cook [email protected] \u003c/p\u003e\n\u003cp\u003eAleksei Kralko [email protected]\u003c/p\u003e\n\u003cp\u003eNaimdzhon Malikov [email protected] \u003c/p\u003e\n\u003cp\u003eMyroslava Filippovych [email protected] \u003c/p\u003e\n\u003cp\u003eAla Iatco [email protected] \u003c/p\u003e\n\u003cp\u003eAlisher Latypov [email protected] \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e \u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence, 2019.\u003c/li\u003e\n\u003cli\u003eWHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users \u0026ndash; 2012 revision. Geneva; World Health Organization, 2012.\u003c/li\u003e\n\u003cli\u003eWHO. Access to Hepatitis C Testing and Treatment For People Who Inject Drugs and People in Prisons \u0026mdash; A Global Perspective. Policy Brief; Geneva, WHO, April 2019.\u003c/li\u003e\n\u003cli\u003eWHO. Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations - 2022 update. Geneva; WHO, 2022.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization Model List of Essential Medicines \u0026ndash; 22nd List, 2021. Geneva: World Health Organization; 2021 (WHO/MHP/HPS/EML/2021.02). \u003c/li\u003e\n\u003cli\u003eHarm Reduction International (2022) Global State of Harm Reduction 2022. London: Harm Reduction International.\u003c/li\u003e\n\u003cli\u003eSafranchuk I. Russia in a Reconnecting Eurasia. CSIS, September 30, 2016. Accessed on 17 September 2023 at https://www.csis.org/analysis/russia-reconnecting-eurasia \u003c/li\u003e\n\u003cli\u003eKlyueva A, Tsetsura K. Strategic aspects of Russia\u0026rsquo;s cultural diplomacy in Europe: Challenges and opportunities of the 21st Century, by Catellani, A., Trench, R. and Zerfass, A., Brussels: PIE Peter Lang, 2015.\u003c/li\u003e\n\u003cli\u003eGolichenko M, Elliott R. Drug laws and policies in four regions of Eurasia. Eastern and Central European and Central Asian Commission on Drug Policy (ECECACD). November 2021.\u003c/li\u003e\n\u003cli\u003eSarang, A., Stuikyte, R., \u0026amp; Bykov, R. (2007). Implementation of harm reduction in Central and Eastern Europe and Central Asia. International Journal of Drug Policy, 18(2), 129-135.\u003c/li\u003e\n\u003cli\u003ePates, R, Riley, D (Ed.). Harm Reduction in Substance Use and High-Risk Behaviour: International Policy and Practice. Addiction Press: ISBN: 978-1-405-18297-3, July 2012. \u003c/li\u003e\n\u003cli\u003eStuikyte, R. (2021). Perception of drugs in Central and Eastern Europe and Central Asia: overhaul needed. Eastern and Central European and Central Asian Commission on Drug Policy (ECECACD).\u003c/li\u003e\n\u003cli\u003eElovich, R., Drucker, E. On drug treatment and social control: Russian narcology\u0026apos;s great leap backwards. Harm Reduct J 5, 23 (2008). https://doi.org/10.1186/1477-7517-5-23 \u003c/li\u003e\n\u003cli\u003eDvoryak, S. Evaluation of effectiveness of drug treatment programmes in Ukraine. Heroin Addiction and Related Clinical Problems 2004: 6(3): 33-36.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2004). The practices and context of pharmacotherapy of opioid dependence in central and Eastern Europe (No. WHO/MSD/MSB/04.1). World Health Organization.\u003c/li\u003e\n\u003cli\u003eLatypov A. Opioid substitution therapy in Tajikistan: Another perpetual pilot? Int J Drug Policy. 2010 Sep;21(5):407-10. doi: 10.1016/j.drugpo.2010.01.013. Epub 2010 Feb 24. PMID: 20185288.\u003c/li\u003e\n\u003cli\u003eCountry reported OAT coverage for the Global AIDS Monitoring report was taken from the database of the Joint HIV/AIDS Programme on HIV/AIDS (UNAIDS) available at https://aidsinfo.unaids.org, accessed on 14 June 2023\u003c/li\u003e\n\u003cli\u003eEMCDDA. 2022 Statistical Bulletin, accessed on 14 June 2023 at https://www.emcdda.europa.eu/data/stats2022_en [data for Latvia and Lithuania only as they were absent in the UNAIDS database].\u003c/li\u003e\n\u003cli\u003eHrytsenko Y. Fight for life: how Ukraine is fixing medical procurement and serving patients better [Internet]. Open Contracting Partnership. 2021. Accessed on 25 February 2024 at https://www.open-contracting.org/2021/02/22/fight-for-life-how-ukraine-is-fixing-medical-procurement-and-serving-patients-better/\u003c/li\u003e\n\u003cli\u003eVeljanov, Z. and Fazekas, M. (2023). Efficiency gains from anti-corruption in pharmaceuticals procurement: Analysis of 9 countries across 3 continents. GTI-WP/2023:04, Budapest: Government Transparency Institute.\u003c/li\u003e\n\u003cli\u003eHuffstetler HE, Bandara S, Bharali I, Mcdade KK, Mao W, Guo F, Zhang J, Riviere J, Becker L, Mohamadi M, Rice RL, King Z, Farooqi ZW, Zhang X, Yamey G, Ogbuoji O. The impacts of donor transitions on health systems in middle-income countries: a scoping review. Health Policy and Planning. 2022 Nov;37(9):1188\u0026ndash;1202. https://doi.org/10.1093/heapol/czac063.\u003c/li\u003e\n\u003cli\u003eHirschhorn, L.R., Talbot, J.R., Irwin, A.C. et al. From scaling up to sustainability in HIV: potential lessons for moving forward. Global Health 9, 57 (2013). https://doi.org/10.1186/1744-8603-9-57. \u003c/li\u003e\n\u003cli\u003eOberth G., Whiteside A. What does sustainability mean in the HIV and AIDS response? African Journal of AIDS Research 2016, 15: 1\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKFF \u0026amp; UNAIDS (2023). Donor Government Funding for HIV in Low- and Middle-Income Countries in 2022. Accessed on 17 September 2023 at https://files.kff.org/attachment/Report-Donor-Government-Funding-for-HIV-in-Low-and-Middle-Income-Countries-in-2022.pdf \u003c/li\u003e\n\u003cli\u003eThe Global Fund (2023). Projected transitions from Global Fund country allocations by 2028: projections by component. February 2023 update. Accessed on 10 December 2023 at: https://www.theglobalfund.org/media/9017/core_projectedtransitionsby2028_list_en.pdf \u003c/li\u003e\n\u003cli\u003eStuikyte R, Varentsov I, Cook C, Dvoriak S. Measuring sustainability of opioid agonist therapy programs in the context of transition from global fund support. Harm Reduction Journal. 2024 Dec;21(1):1-2.\u003c/li\u003e\n\u003cli\u003eIatco A. Republic of Moldova: Assessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. Vilnius, Lithuania: Eurasian Harm Reduction Association (EHRA), 2020.\u003c/li\u003e\n\u003cli\u003eKralko A.A., Republic of Belarus: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding. EHRA, February-April 2020. \u003c/li\u003e\n\u003cli\u003eDvoryak, S, Zeziulin, A. Украина: Анализ устойчивости программ поддерживающей терапии агонистами опиоидов в контексте перехода от донорской поддержки к национальному финансированию. [in English: Analysis of the sustainability of opioid agonist maintenance therapy programme in the context of transition from donor support to domestic funding]. Kyiv, February-April 2020. \u003c/li\u003e\n\u003cli\u003eLatypov, A. Republic of Tajikistan: Assessment of the Sustainability of the Opioid Agonist Therapy Programme in the Context of Transition from Donor Support to Domestic Funding, EHRA, February-March 2020. \u003c/li\u003e\n\u003cli\u003eKralko A.A. Republic of Belarus: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, Lithuania, 2023. \u003c/li\u003e\n\u003cli\u003eMalikov N (2023). Tajikistan: Reassessing the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. \u003c/li\u003e\n\u003cli\u003eIatco A. Republic of Moldova: Reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023. \u003c/li\u003e\n\u003cli\u003eDvoryak, S, Filippovich, M. Ukraine: reassessment of the sustainability of the opioid agonist therapy programme within the context of transition from donor support to domestic funding. EHRA: Vilnius, 2023 \u003c/li\u003e\n\u003cli\u003eStuikyte, R et al. Independent Review of the Ukraine\u0026rsquo;s Transition Plan 2018-2021. PAS Center: Chisinau, Moldova, 2022. Accessed on 01 October 2023 at: https://www.phc.org.ua/sites/default/files/users/user90/Ukraine%20TP%20review_FINAL%202-15_2023_last.pdf\u003c/li\u003e\n\u003cli\u003eNational statistical committee of the Republic of Belarus. Statistical bulletin No: 26/170p \u0026laquo;Численность населения на 1 января 2023 г. и среднегодовая численность населения за 2022 год по Республике Беларусь в разрезе областей, районов, городов, поселков городского типа\u0026raquo; [in Russian. Population as of January 1, 2023 and the average annual population for 2022 in the Republic of Belarus by regions, districts, cities, urban settlements]. Belstat: Minsk, 2023. Accessed on 15 January 2024 at: https://www.belstat.gov.by/ofitsialnaya-statistika/solialnaya-sfera/naselenie-i-migratsiya/naselenie/statisticheskie-izdaniya/index_67489/ \u003c/li\u003e\n\u003cli\u003eState Statistics Service of Ukraine. Demographic situation in 2021. Macroeconomic indicator 12 June 2023. Kyiv, 2023. Accessed on 15 January 2024 at: https://stat.gov.ua/en/publications/demographic-situation-2021.\u003c/li\u003e\n\u003cli\u003ePublic Health Center of the MoH of Ukraine Official statistics on the opioid substitution treatment program in Ukraine. Kyiv. 2014-2023. 2023. https://phc.org.ua/kontrol-zakhvoryuvan/zalezhnist-vid-psikhoaktivnikh-rechovin/zamisna-pidtrimuvalna-terapiya-zpt/statistika-zpt\u003c/li\u003e\n\u003cli\u003eSerebryakova L et al. Failure to Fund: The Continued Crisis for Harm Reduction Funding in Low- and Middle-Income Countries. Harm Reduction International: London, 2021. \u003c/li\u003e\n\u003cli\u003eZhao F, Benedikt C, Ward K. HIV and Allocative Efficiency in Eastern Europe and Central Asia. Tackling the World\u0026rsquo;s Fastest-Growing HIV Epidemic. World Bank: Washington D.C, July 2020. \u003c/li\u003e\n\u003cli\u003eHolt E. Difficult choices for people with HIV in the Donbas. The Lancet HIV. 2024 Jan 8.\u003c/li\u003e\n\u003cli\u003eAzzopardi-Muscat N, Zapata T, Kluge H. Moving from health workforce crisis to health workforce success: the time to act is now. The Lancet Regional Health\u0026ndash;Europe. 2023 Dec 1;35.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Opioid agonist therapy, methadone, buprenorphine, injecting drug use, Eastern Europe, Central Asia, drug treatment, transition, sustainability","lastPublishedDoi":"10.21203/rs.3.rs-4021071/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4021071/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMost national programmes of opioid agonist therapy (OAT) in Eastern Europe and Central Asia are at a critical juncture for building their sustainability due to decreasing support from the Global Fund and other international HIV funders. Therefore, it is timely to identify the status, trends, opportunities and risk factors of OAT preparedness in the face of donor transition.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study assessed the OAT sustainability progress in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine. The national assessments were conducted in 2020 and repeated during 2022\u0026ndash;2023. In total, 363 sources were reviewed and used, 83 interviews with key informants and 13 focus groups were conducted with clients, using a joint methodology and a defined Framework with three dimensions: \u0026lsquo;\u003cem\u003ePolicy \u0026amp; Governance\u003c/em\u003e\u0026rsquo;; \u0026lsquo;\u003cem\u003eFinance \u0026amp; Resources\u0026rsquo;\u003c/em\u003e; and, \u0026lsquo;\u003cem\u003eServices\u0026rsquo;\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll four countries have made improvements to increase OAT sustainability, though it varied. In 2022, Ukraine had a substantial degree of sustainability, followed by Belarus and Moldova with a moderate degree, while Tajikistan\u0026rsquo;s sustainability was at moderate-to-high risk. No country achieved a high degree of OAT sustainability in any of the three dimensions measured. However, a high degree of sustainability was reported for at least one indicator in Belarus, Moldova and Ukraine: \u0026lsquo;\u003cem\u003eMedicines\u0026rsquo;\u003c/em\u003e; \u0026lsquo;\u003cem\u003eFinancial resources\u0026rsquo;\u003c/em\u003e; \u0026lsquo;\u003cem\u003eEvidence and information systems\u0026rsquo;\u003c/em\u003e; \u0026lsquo;\u003cem\u003eService Accessibility\u0026rsquo;\u003c/em\u003e; or, \u0026lsquo;\u003cem\u003eService integration \u0026amp; quality\u0026rsquo;\u003c/em\u003e. On average, the greatest improvement between 2020 and 2022 was seen for \u0026lsquo;\u003cem\u003eAvailability \u0026amp; coverage\u0026rsquo;\u003c/em\u003e; \u0026lsquo;\u003cem\u003eFinancial resources\u0026rsquo;\u003c/em\u003e; \u0026lsquo;\u003cem\u003eService quality \u0026amp; integration\u0026rsquo;;\u003c/em\u003e and, \u0026lsquo;\u003cem\u003eService accessibility\u0026rsquo;\u003c/em\u003e. The highest risks across the countries, notably in Belarus and Tajikistan, were recorded for the indicator, \u0026lsquo;\u003cem\u003eAvailability and coverage\u0026rsquo;\u003c/em\u003e. Of concern is that the least progress, or even a decline, was found in \u0026lsquo;\u003cem\u003eHuman resources\u0026rsquo;\u003c/em\u003e within the sustainability indicator.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOAT sustainability in 4 analysed countries remains at risk, although those countries are at a different point of donor transition. OAT resilience and ability to scale up depend upon multiple factors. Political will and continued funding are two of them, as demonstrated by Ukraine\u0026rsquo;s progress despite challenges posed by Russia\u0026rsquo;s full-scale invasion in 2022. The results show that both financial and programmatic areas are at risk and stagnating progress requires collective efforts.\u003c/p\u003e","manuscriptTitle":"Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-12 18:44:12","doi":"10.21203/rs.3.rs-4021071/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-11T23:50:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-11T11:21:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-06T16:52:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97148256486882024007081178138072881818","date":"2024-04-30T05:29:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58996844310671641795310224480007785418","date":"2024-04-26T07:44:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f83a2dae-67ff-4a71-adee-7be48ba17074","date":"2024-03-11T09:00:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-09T08:49:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-08T09:28:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-08T09:28:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2024-03-06T12:59:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e81732bd-be00-4329-82ad-77882447d11a","owner":[],"postedDate":"March 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:05:15+00:00","versionOfRecord":{"articleIdentity":"rs-4021071","link":"https://doi.org/10.1186/s12954-024-01050-6","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2024-10-16 15:58:13","publishedOnDateReadable":"October 16th, 2024"},"versionCreatedAt":"2024-03-12 18:44:12","video":"","vorDoi":"10.1186/s12954-024-01050-6","vorDoiUrl":"https://doi.org/10.1186/s12954-024-01050-6","workflowStages":[]},"version":"v1","identity":"rs-4021071","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4021071","identity":"rs-4021071","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}