 Good morning to all. My name is Daniel Wolfe. I'm the director of the Harvard Ocean Program at the Open Society Foundations, and I'm very pleased to welcome you to this session. We heard yesterday in the opening ceremony that the theme of the conference is leadership. And of course, one extremely important part of leadership or expression of leadership is how much money people are willing to put toward the cause that they believe in. And that is the subject of our discussion here this morning. This is not a PowerPoint presentation-driven session. It is a moderated informal conversation. We have a distinguished panel representing various viewpoints. I'm not going to read the full biographies of all the participants, but let me just give you a brief summary of some of their most important accomplishments. To my immediate left is Dr. Shari. He is the deputy director of disease control and the head of the AIDS response in Malaysia on behalf of the Ministry of Health. And he's also the executive secretary of the country coordinating mechanism which engages with the Global Fund. So we'll be asking him to speak from both perspectives. To his left is Mareika Windrocks. She is the chief of staff at the Global Fund. Many of us have known her in her other incarnations because she has also been a representative of the Dutch government working on various issues. She was the ambassador for HIV-AIDS and sexual and reproductive health and rights and the deputy director of the social development department. To her left, Lambert Reims. And he is the current director of the social development department and special ambassador for sexual and reproductive health and rights in HIV-AIDS. So I assume he and Mareika have much to discuss in their current roles. And I assume that speaks to one reason why the Dutch government has been such an important collaborator with the Global Fund. And finally to Lambert's left is Pascal Tange. He has been, he was for many years the lead representative for the, that part of the Global Fund grant in Thailand was responsible for implementing HIV prevention for injecting drug users. That program was called the Champion IDU. And he is currently the board member of the Ozone Foundation which is the current implementer of HIV prevention activities for people who inject drugs in Thailand. So we have a range of perspectives represented and I guess I want to start with the obvious which is that many of us in the room are worried that there is less money for harm reduction at precisely a time and as we saw yesterday and as we'll hear we need to be scaling up. So I want to ask each of you to briefly just answer the question what are you personally doing to ensure scale up of funding for harm reduction? And if, with apologies, because we want to leave time for questions try to keep your answers relatively brief so that we can have some exchange with the audience. So Dr. Shari, you're on the hot seat first. Thank you. Thank you. And panelists, ladies and gentlemen. Regarding these countries, before I embark on this program of harm reduction bear in mind that the first step of the country is trying to tackle our response to this epidemic started in 1985 with a various approach through providing education, providing services through contact tracing, certification, surveillance, treatment, and so on. There are tremendous numbers of initiatives being done covering primary, secondary, tertiary prevention in this country. And for the harm reduction program it was started in 2005 and bear in mind that in this country we believe on the three P's. Number one, the political will, number two is a policies, workable policies and the number three is participation. We start from the first P but the political will, not only here, we'll try to drive the way we try to do but the political will also try to ensure adequate funding for our prevention. That's why through the political way the government endorsed the way that we try to do and about harm reduction since on that particular time 70% of our cases are among the people who use drugs. That's why we start to have a little exchange program together with harm reduction, treatment, and therapy and that particular time government didn't think of external funding. We start thinking of how the way the government should do in addressing this issue through our domestic funding. That's why in that particular time the government already made a policy that methadone program the government will purchase the methadone through our existing facility and the government also will purchase needle exchange program, whatever brand that the person who use drugs needs that kind and then we fund that money through the Malaysian Health Council and at the same time the government believes that government cannot work in silo they have to work with the Malaysian Health Council as one of the umbrella body or non-government organization and government make a commitment to fund the Malaysian Health Council and their partner organization to implement that program. Is it an actual dollar commitment? The methadone program government park 14 million ringgit until today we have not finished at the 14 million ringgit annually and for the needles program government park 5 million ringgit to purchase needle exchange. On top of that also we complement 1 million, 1.5 million for condom and at the same time we make a commitment around 6 to 7 million ringgit also to fund the non-government organization Malaysian Health Council. This is the way that we are committed to do so. Thank you. So let me turn to Marika. This is exactly what the Global Fund is often saying they want governments to do and at the same time we know that not all governments are the Malaysian government and I personally visit many government officials who will say privately I have no intention of paying for needle insurances let the Global Fund do that. So what is the Global Fund how are you thinking about funding scale up in this complicated dynamic? Thank you Danielle. Just as a starting point I think we all agree that the funding situation funding gap for harm reduction is really quite dramatic and the donor landscape is actually becoming smaller rather than larger and we just discussed before going to the stage that it's not basically the Netherlands and there's not so many other bilateral donors left at the U.S. that really fund harm reduction programs. So the Global Fund from the start has been an advocate for evidence-based interventions including harm reduction and we are still the single largest donor funding harm reduction programs. Up to 2014 we spent 620 million on harm reduction programs of people in fact programs targeting people inject drugs more broadly in 58 countries and we are now in the middle of our current replenishment cycle and tracking how funding is going and at least at the moment there's no indication that that would decline and we hope there will be actually further increases because one of the this is the first time in a strategy that we have an explicit objective on human rights so there's a greater focus on human rights and key populations and our board is in the middle of discussing the strategy 2017-2020 and if one thing will be even greater focus on human rights I think policy wise we are in a good spot so what we do to encourage investment in harm reduction especially in some of the middle income countries that will gradually have to take over a greater part of financing is for example the team for Eastern Europe and Central America Central Asia they developed a guidance note to track investments and to guide countries on how to apply for global funding and that is very much focused on key populations and all efforts that support programs targeting key populations and the team is tracking whether the concept notes that come in actually do that and so far there's 100% compliance it's quite strict guidance I have to say so what we do for the upper middle income countries is that there's now very strict guidance that all support that the Global Fund provides targets key populations and we assume that countries take on like the general programs, the treatment, the general programs so that's we really do not see a role for the Global Fund in funding that in upper middle income countries and while not all donors on the board are very comfortable with the Global Fund engagement in upper middle income countries as long as the focus is strictly on key populations they're okay because they see there's value added and key populations so that's what we do for the Global Fund in many countries so I think moving forward we can maintain that focus when it comes to the overall funding situation of course we have to take into account that the overall environment is not very positive so we will be having our next replenishment in 2016 and in an environment where there's many competing priorities we have the climate conference in Paris we have an SEG agenda that's much broader an unprecedented refugee crisis affecting Europe so we really will do our very best to go for a good replenishment a good outcome but I think it's also to be realistic the environment is not a very positive one at the moment so let me turn to Lambert as Marika mentioned if we were having this conversation 10 years ago and we invited donors present up to the podium we would have had DFID, ASEID obviously there's no longer any ASEID but we would have had many more countries and now we are very grateful to have you but curious and concerned that the idea that middle income countries should take care of their own is a kind of theory of overseas development assistance that seems to focus more on gross national income than on inequality within countries and for those of us who work with drug users people who inject drugs are often in richer countries but still aren't getting any services from the government how is the Dutch government thinking about this question of investment in middle income countries and same to you as to all the other panelists how are you ensuring that funding for harm reduction grows rather than shrinks good morning thank you very much Daniel let me start by congratulating the Malaysian government for their tremendous achievements of the last couple of years decrease of HIV incidence by 50% of the last nine years which is mainly due to their investments in harm reduction which for me is a perfect example of what a government can do you spoke about political will and the responsibility a government should take and that's exactly also the answer to your question I think why if you want to really scale up and if you really want to make a difference as a government you have to take responsibility now let me first look at the broader picture because worldwide the picture is not as positive as in Malaysia HIV incidence worldwide amongst people who inject drugs is decreasing only very very slowly in the year 2010 there was an HIV incidence amongst people who inject drugs of about 110,000 people and it slowly decreased to about 100,000 people which is only 10% decrease in about three years and if you look at the countries which introduced harm reduction policies it's a little bit over half of the countries which have documented some drug use so 90 countries worldwide more or less with OSD programs in a way it's encouraging on the other hand it is way too little now and yes you're right there are only a few international donors such as Global Fund and very few bilateral donors such as the Netherlands which are willing to provide support on harm reduction unfortunately the Netherlands is one of the very few donors that used to be a bit more but even we think that in the end governments should take their responsibilities so domestic resource revenue funding, domestic resource mobilization should indeed be our key focus having said that what can we do as a bilateral donor maybe I can give you a few examples of what we have been doing to do in the next couple of years we just last month introduced a new extension of a program which we are funding it's called bridging the gaps working through Dutch and international and local NGOs focusing on service delivery to a couple of countries on top of that very interesting we are going to start next year with a program which is a huge program which is focusing on strengthening the capacity of local NGOs to lobby and at focus to hold their own governments accountable and remind those governments of the political will so that's not directly focusing on the governments but on civil society so that civil society can help improve conditions in their own country with government funding another example is a strategic partnership which we have with the international HEVH alliance which is still to be negotiated actually we do have a very interesting trilateral cooperation with UN 8 with NGOs working on the bridging the gaps program Dutch and local NGOs and our embassies as well as local organizations in three countries Indonesia, Kenya and Ukraine where we basically try to support better cooperation amongst key populations and finally one thing which you know but we will have we will host in the year 2018 in Amsterdam the international HEVH conference last year Melbourne next year Durban and in 2018 in Amsterdam and Amsterdam we are focusing on key populations including harm reduction now that does not give an answer to your question why only the Netherlands is left amongst those donors but probably it gives some inspiration and ideas to other donors to step in and help us with this endeavor okay thank you and I want to maybe turn up the heat a little bit and I do want to recognize the incredible leadership of all of you and I also want to say that these questions of governments taking over and transition are not as simple as they sound there are numerous instances where governments say they're going to take over the donor leaves and indeed nothing is taken over I'm thinking for example of Serbia I'm thinking of Romania I'm thinking of a number of countries where the exit of international donors meant the collapse of harm reduction programs countries where the transition is underway where the government says it will take over sometime soon and we have signs that things are not always not well and I actually wanted to ask Pascal because you sit in a so-called transition country moving from global fund support for harm reduction to national support for HIV programming and I guess the question is how is it going and what do you wish people like or entities like bilateral donors of the global fund understood more clearly thank you Daniel I think the first thing that's important to understand about Thailand is that the Thai government made the decision in late in 2014 to fully finance the national HIV response as the first of January 2017 obviously there was not a lot of money coming to Thailand in the new funding model so the Thai government with support from civil society decided to use the new funding model as a transition period the actual implementation of that transition was never discussed and outlined in detail but there was support even from civil society to move towards a fully nationally financed national HIV response however since the beginning of that transition since the beginning of the new funding model there's been a lot of challenges we had a large project called champion IDU that was operating for five and a half years that reached approximately 50% of the total injecting drug user population in Thailand all the services all the components have been scaled down so we work in fewer provinces we no longer work in prisons we had this private public partnership with private sector pharmacies to distribute needle and syringes and other equipment that's been cut out a lot of the support systems and a lot of the support systems have been cut out to protect our staff from undue abuse from law enforcement in the field as well as the funding for advocacy has been now centralized under one subrecipient so our organization no longer has the capacity to directly advocate for our own population these have led to many complications in the field and we're essentially to kind of answer the same question that has been asked from every other panelist what we've been doing is trying very hard to protect the successes that were there in 2014 unfortunately we've not been able to do that but we have identified a lot of the risks way back in 2013 and initiated discussions with the global fund at least communication with the global fund and global fund representatives working on Thailand issues fortunately after more than 25 communications with global fund representatives we still haven't even had a chance to sit down and dialogue and look at those risks explicitly and come up with a plan to address those risks properly so I want to go to Dr. Shari and then I'll come to Marika but obviously and this is not meant to be a forum on a particular country but and more about the sort of dynamics of transition but you are also undergoing a transition you receive global fund support you will never receive it again what are you doing to plan for the transition and I mean it's a different situation to Thailand because as we have already heard you invested from the start but I'm still curious how are you thinking about making sure that the transition doesn't result in the kinds of service disruptions we just heard about thank you Dana and regarding the international donor especially from the global fund and also receive from international alliance actually from the beginning the government didn't think of external funding we are keep thinking on domestic funding because to be the responsible government they must understand what is the needs of the people that's why we are looking that way and we are very fortunate the global fund and international alliance did extend their arm to us since 2010 2011 and thanks for these two organizations that allow us to extend in such way in that speed to reach almost 85% of people who use drug through the 100% program and for your information the domestic funding divided into two one is a domestic public and the other one the domestic private domestic public come about 10% of our budget for last year and for your information in 2013 and 2014 there is 10 million different of the domestic public by the government means the government top up in 10 million from 2013 to 2014 increase and domestic private almost maintained at the level of 2 millions and for international finding international alliance and global fund around 4% to 5% of our funding to the it works and from the beginning once the government agreed to receive those funding we are keep thinking that the funding should be for the non-government organization rather than from the government that's why we channel all those money to the non-government organization for them to extend in that speed to reach all those people and we are also negotiating the global fund last two weeks how we try to make a transition and we are very committed amount of money given through the global fund project once you leave us in 2017 or maybe 2018 we are ready we are ready to absorb those kind of activity at our terms so we are not looking to the amount of money through our terms but we are looking to the workable approach rather than approach that being tabled out what we call it is that we want to have a strategic approach with the strategic partner and our strategic partner always with non-government organization and even also in the private so we try to make it such a way that what benefit to the people the community should be on the shoulder of the government it should be sure also the best asset for us is our people thank you so that sounds excellent and I have to say I've heard that before from other governments and yet the reality is sometimes when it's actually all you there are certain populations and I'm not saying this about Malaysia actually it's really a question for Marika which is that we see governments who say they will take on the response to actually paying for certain politically unpopular interventions like needle and syringe programming or to giving money to NGOs rather than to routing it through their own channels suddenly the commitment turns into something else avoidance and I can give examples of many countries I just came from northern Mexico the overall HIV response the government is stepping up on harm reduction which was funded by the global fund those programs basically were radically slashed and never came back and there was no plan and the NGOs that were there you know they get donations from government of some needles but there's no plan and I guess it's a question as we move toward transition and as we move toward funding allocations that are based on some combination of income level and disease burden how can we better plan for transition and I guess maybe what lessons has the global fund also been learning learning as you go well first of all I wish that all countries were like Malaysia and you could have a serious discussion about transition but the sad reality is that that's not the case and also to be very open that the global fund doesn't really have a track record in transition so far we worked before under around based models so countries could submit proposals in calls for proposals and all of a sudden countries were like oops we're not eligible anymore so it would be called turkey transition so I'm totally very open about that we don't have a strong tracker on transition and the examples that you gave like Serbia and Romania are just expressions of that because there was never any proper planning and going forward and with support building on three year allocations and with the information you have on economic growth at least we are working out towards transition planning sustainability which is a key component which will be a key component in our next strategy but that doesn't mean that it still will be easy then even if you have and we acknowledge that transition requires time so Thailand as Pascal said it was the Thai government that decided to fund their own programs and towards ending age in 2030 which obviously we applaud and we've been working closely with the Thai CCM and the government to work on transition planning and has been many set aside to support civil society to build capacity and very importantly to change legal frameworks because in many countries government cannot is constitutionally not able to support civil society but it's also clear from Pascal's statements that even if you try the best you can that there's concern there's problems that occur in a way and it also was very clear talking and listening to Pascal that we need to engage more closely with civil society in Thailand to really get the full picture the CSO group that's monitoring transition is currently led by Raksthai a civil society organization but I think it would be helpful to have a broader engagement with broader civil society in Thailand to really discuss what are the real problems and how can we collectively address them if we want to end AIDS then people inject drugs and harm reduction programs should be a key element of the response and supported by national government so very committed to work with Pascal and colleagues to try to find a solution to this we have apart from the thinking about the transition planning we have a number of things we're thinking about or already in place to help those transitions but the first is to work with a number of other organizations and initiatives where we try to see whether it would be possible to develop a framework to define needs and eligibility that it's more refined than what we currently have in terms of GNI and disease burden because that's quite a blunt tool and doesn't really reflect inequality in countries another thing is that we have our community rights and gender team led by K Thomsen who is sitting there also part of a special initiative 15 million over the three year current replenishment cycle to support civil society capacity building and part of it is to do advocacy but also to build the capacity of civil society at country levels to better deliver, better advocate it's another part we just start exploring different models of community based monitoring as a way to then monitor transition and what's actually happening on the ground at the capital level we have a number of regional programs now in place around people inject drugs and harm reduction, the Eurasian harm reduction work network was the first one and I'm really excited about the progress that they make because they're advocates but also monitor and publish what governments are funding and I think these examples of accountability and just demonstrating what countries actually do are increasingly going to be really important in transition countries we have another program just approved in Eastern Africa and three in the pipeline for another one for Eastern Europe focusing on cities, West Africa and Asia so I think those are again important components of transitional accountability and lastly Lambert mentioned the bridge in the gaps program I obviously know the bridge in the gaps program very well and we've had discussions with them in the lead up to the current proposed to see how we can also use the piggyback and link with the networks that are supported through bridge in the gaps to see how we can also use that as a tool for capacity building that for the country level. Can you imagine any scenario because for example the EHR and the Eurasian harm reduction network grant that you mentioned did do excellent work and actually getting governments to also describe their commitment but in some cases for example the Republic of Georgia the government said yes and we want to be clear we intend to commit zero to needle exchange needle and strange programming in the coming years is there any scenario where the global fund could imagine some kind of special channel or a particular intervention or way to sustain key interventions that you know whether it's in Thailand or in Georgia that the government actually does not intend to pick up I think at the moment the reality is we do pick up a lot of it but that should be a part of a broader dialogue. I think then the strong point about the Eurasian harm reduction network is that we have it on paper now zero commitment and that provides a very important advocacy tool and that's going to be part of the discussion with the Georgian government going forward so how will global fund then develop if the government is not going to put in any money for NSP programs and which is a key program of tackling HFE in Georgia and how we kind of push that and we do have leverage because of funding. We also have to be clear that the leverage in some of the Eastern European countries is not that big we will not be able to totally influence policies but at least it does help and we've had at least in some countries we've seen that through the policy dialogue and engagement with national stakeholders and civil society we have been able to push governments to take more but this is absolutely a key issue going forward. So Lambert you mentioned the importance of advocacy and I think you know for better and worse it is a common theme that my program also we say now we usually we don't support services but we support advocacy to monitor and press the government for commitments because that's the answer in the longer term. I fear that as all of us say the same thing there is actually a gap for services because advocacy is most effective when it's based on genuine services and indeed if everyone says they won't pay for services it becomes complicated like you can advocate and document but meanwhile much that has been built can be lost. I'm curious when you think about sustainable transition how you think about that question and Dutch commitments. There's much to be said about that but of course we work very closely together with the Global Fund. We are a sponsor, we are funder of the Global Fund so we are having those discussions as well of course with the Global Fund although we have a different position being a bilateral donor. Let me say first of all there's this OECD platform in Paris where bilateral donors together discuss this whole phenomena of how much percent of our what is the percentage of our ODA want to spend on lowest developing countries and on middle income countries and the deal is that 0.15 percent of ODA would now be spent on lowest developing countries and in three years time it will be 0.2 percent so one fifth of ODA that's what we agreed upon in Paris will be spent on lowest developing countries and it leaves enough room for investments in middle income countries but speaking about advocacy maybe one more issue which we can do as a bilateral government and I hope the Malaysian government will join us there. The UNGAS of course I mean it's a completely different level of advocacy but that will definitely be one of the occasions where we can raise this issue to be one of the issues where really there is an opportunity to opportunity for change and it would be excellent if not only the Dutch government but many other governments worldwide could really raise the point and show that maybe harm reduction is not so controversial as some other countries tend to think I think worldwide many many governments are struggling they have harm reduction programs in place at the same time there is a lot of criminalization and a lot of very strong law enforcement which is not very consistent and I see governments literally struggling with that dilemma because of the simple fact that harm reduction belongs to one ministry and law enforcement belongs to the other ministry that's a normal thing and I think we are all in that transition it's another transition than the one which you mentioned but I hope the UNGAS will be a great opportunity for governments to have more experience and maybe for us to also show our Dutch experience where we introduced harm reduction even before the word existed 35 years ago now you mentioned Georgia I was in Tbilisi a couple of weeks ago and yes there is typically an example of a country which is I think willing to take responsibility countrywide ART coverage and yes they are indeed also willing to take responsibility for funding on their side but what I missed in that discussion was that the more contentious or more difficult part of government responsibility is dealing with for instance anti-stigma or discrimination campaigns or literacy or indeed when it comes to OST or needle exchange programs that's much more difficult because as a government we are willing to temporarily compensate but at the same time of course we are not willing to take the role of the one who is funding those programs and serve delivery which a local government or in the end the global fund does not want to fund so we are quite consistent with the global fund in saying that look governments you have to take your own responsibility what we think might be helpful is when we support indeed civil society in playing their role as an advocate and as lobbyists at the national level that's a role which maybe is easier for a bilateral donor than for instance the global fund so Pascal you are in a country where indeed that kind of assistance is needed civil society is advocating and has been advocating and yet they could use some friends I'm curious and this I think is a very important point but it's also the policy environment and Thailand is another place where there's a challenging policy environment and where there's law enforcement skeptical about needles and where the government has also said we don't intend to fund these things what kind of help could you use from others of us in this room particularly bilaterals or international donors that's a very good question and what needs to happen in Thailand is to clarify the situation in regards to that transition plan right now depending on who you ask everyone's got a different answer whether there is a transition plan or even whether the transition is happening or some have even called it a success a year 14 months before it was it's even finished now people are claiming success in Thailand's transition that's Ozone, our organization there's to our knowledge not a single dollar that's been committed to support the actual implementation post January 2017 so that services can continue to be delivered to people in the field if you follow me just temporarily down a little rabbit hole when I was the principal recipient of the Global Fund before we could access a single penny from the Global Fund a management plan, a financial plan a data management plan we needed to prepare about 10 to 20 plans and documents to ensure the Global Fund that what we were doing was going to follow the plan in Thailand there is no transition plan the plan is being finalized now when we're already 10 months into that transition where I'm from that's called making it up as you go along not transition planning that's a key problem for these transitions to be successful the plans need to be in place before the transition starts there needs to be agreement and consensus including from civil society groups on what is going to happen after the Global Fund pulls out without that consensus in place it's kind of irresponsible to let a country like Thailand and expect them that they will miraculously, spontaneously start funding harm reduction nationally in Thailand the transition that's been planned so far has been essentially based not on evidence but on people's feelings especially in terms of harm reduction we set up in our project in 2009 to 2014 we collected over 50 data points about each one of our clients five and a half years of longitudinal data when the planning for the transition started not a single entity or organization came to look at our data which is a big concern considering that essentially we were the repository for data about injecting drug users in Thailand and no one's bothered to look at that data the systems that we use to collect data are no longer in place the data remains and we don't have the capacity to analyze that data or to do research with it nor does any of our partners that are funded through the global fund in this particular transition one of the things that would be very helpful for us is to have some partners particularly from academia to come and help analyze that data and produce some publications or evidence that helps the Thai government make evidence-based decisions second thing I think where we need a lot of help is under our project under the previous project where we were able to advocate over the five years and we were successful in getting the national harm reduction policy passed endorsed by the government in September 2013 it was deployed in October 2014 unfortunately because of the transition advocacy was cut out from our program we cannot do direct advocacy anymore and so no advocacy since the beginning of 2015 was done to maintain that policy in September this year the policy expired there is no more harm reduction policy in Thailand it has expired we are back to pre-champion IDU policy levels of support in Thailand unfortunately last thing I think that where we need support is for organizational strengthening and capacity building for ozone ozone came out was registered as a local Thai NGO in December 2014 when that transition was happening the PR helped negotiate so that ozone could access some technical support there was budget allocated under the new funding model for ozone about $250,000 apparently that was put into budget specifically for that none of that we have not been able to access any of that technical support funding to date we were told that that money has been reprogrammed without discussion with us and there has been no mechanism to provide any kind of technical support organizational strengthening for ozone so for example, Global Fund expects us to manage the money properly we don't have an accounting software and we don't have money to even purchase an accounting software we don't have logbooks to track what services we provide to our clients in the field again, that kind of we need support from technical service providers to come in and help provide the support to ensure that ozone, which is the organization that delivers about 80% of the volume of harm reduction services to injecting drug users in Thailand that they need to be supported, ozone needs some support if we're going to ensure continuity I think the last key message I want to leave with is that Thailand's transition by some organizations I've already called Thailand's transition of success it seems that they're focusing those people who are calling Thailand's transition of success 14 months ahead of the transition even being finished is kind of irresponsible and it seems to focus more about on process rather than impact it's all great Thailand's aligned, Thailand's made that commitment but on the ground services have been scaled down there's a lot of risks that have not been addressed and fewer services are reaching the people who are most in need so in that respect it's a bit of an illusion and it's a bit contradictory to present Thailand's transition as a success when there's immense challenges that are not even being raised publicly by global fund representatives or even Thai government representatives it's not a surprise because of the political sensitivity around harm reduction but we're relying on organizations like Global Fund which has been the leader funding globally harm reduction programs at national level we'd expect the same level of leadership and in guiding countries into proper responsible transitions towards national funding thank you I don't know if any pressing responses I think this just illustrates that transitioning reality is a really complex process and Thailand in a way is a bit of a special case because the government themselves decided they didn't want to access global funding anymore so we now have a sort of crash transition planning which is far from ideal and I already committed that we'll follow up with the civil society to make sure that there's a broader dialogue with civil society in Thailand to see where we have gaps the other thing is that we since Thailand is actually the only country the first country that really transitions on a voluntary basis we're committed to really documenting and documenting is not that up front we say this is successful but we really document what has worked, what hasn't worked so that we can learn lessons for other countries that will transition I want to actually pick up on something that Lambert raised in the context of the UNGAS but it actually has, is links to something that we heard yesterday about law enforcement spending I want to bring it connected to the funding question again law enforcement spending versus health spending for people who use drugs as we struggle to maintain or even struggle with reductions in funding the reality is that in many many countries there is plenty of money to enforce drug laws to pursue, we talk about people who inject drugs as a hard to reach population the police very often have little trouble reaching everyone because they are well resourced to do so there's a campaign this week called 10x20 to urge governments to commit at least 10% of the amount that they spend on drug enforcement to harm reduction and the estimate is that if that were to occur it would cover all the global needs for harm reduction two years over so I actually want to start with Dr. Sari 10x20 what are your feelings thank you thank you if I comment on that question so let me try to pay your attention in 2005 when we implement the harm reduction program we didn't think about laws on implementing that keep the law aside we try to think what works in this country we did not provide give up with the current law what we try to do we try to monitor whichever we try to do in terms of public health approach in dealing with people who inject them these are health issues it's not an enforcement issues these are the people, these are human need attention on us that's why we try to look at the angle of public health approach that's why we didn't touch we didn't discuss on the laws you said like a doctor and that's why we believe that supply reduction, demand reduction and harm reduction works and depend on how you try to deal that issue they must deal that issue as a human issue all these three must deal it with a human issue supply reduction is a human issue demand reduction must be a human issue and definitely 5L issue is a human issue harm reduction so implementing that how much money needed whatsoever I think we already start at 10% few years ago there may be 20-30% on the drug issue inter-private drug issue and these are the commitments made and even yesterday our minister made a commitment by 2030 or earlier than that Malaysia we can smell ending it maybe 2021 and the first pillar of the approach is reaching 95% of people who use drug into 80% and at the same time 15% money direction why? because we want to treat these people who are currently on drug those being packed on HIV be covered with antiretroviral we are hoping that we are able to reduce transmission of HIV in this country earlier than 2030 through our current approach that's what to me that the amount of money being invested on the harm direction I think it's more than 10% to the law enforcement which is now I think what the current policy is work already okay actually Lambert I wonder if I could ask you the same question I don't know if you know for your own government but also in what you speak about with others thank you very much it sounds appealing right this 10 by 20 campaign at the same time being a government myself I don't know but it's very realistic governments tend to think in terms of projects which you want to combine which in administrative terms is a bit complicated maybe it's more important I think to stress the the importance of decriminalization of drug use which in itself again is also a substantial saving on law enforcement so let's try to rethink harm reduction sometimes we tend to make a clear distinction between prevention and treatment on the one hand and harm reduction on the other hand it's kind of black and white thing or clear dichotomy which I don't agree with they are complementary to each other where prevention and treatment and harm reduction are in line with each other so rethinking of harm reduction as part of our total approach should also be probably helpful and maybe could also be framed from a cost effectiveness perspective harm reduction is relatively cheap I mean from a government's perspective that's also attractive and appealing it's much cheaper I mean the figures you mentioned are clear and convincing harm reduction is much cheaper than law enforcement so but let's try to not oppose these two issues too much especially leading up to the Angaus see where we can make harm reduction kind of natural logical part of our overall approach as governments in the Netherlands we have very much a favor of harm reduction but we are not a favor of legalizing drugs so although drug use is legal so what I want to say is maybe we should be careful in too much polarizing these two issues thank you now first of all I think by any definition of war against drug has been a miserable failure and in the Angaus since we are not a member state we have a bit of a special discussion but just on the law enforcement actually our new senior union rights advisor whom we poached from OSF sorry Daniel he has introduced now for us to see how we can work more with law enforcement agencies because if you work towards decriminalization as your ultimate goal and focus all your energy there it's going to take forever and in the meantime life for people on the ground will not change much but I think there's a lot of positive evidence of working with law enforcement agencies working with the police to at least make sure that they are aware of harm reduction programs and the benefits of harm reduction programs and the benefits of an approach that a public health approach in sort of a criminalization approach that has been really helpful so I think they're also sort of coming back to what Lambert said to not really oppose it because I think law enforcement can also be supporting your programs okay I mean I know that Pascal actually works one of his incarnations is as deputy director of a network law enforcement and HIV network but I'm actually going to ask you to pause I'm conscious that the audience may have questions and we I want to make sure I promise that we'll give you an opportunity but can I invite anyone who has questions about anything that we have talked about so far to I think there are roving microphones and if you would indicate I can't actually see the microphones those people in the orange vests apparently have microphones so can you raise your hand if you have a question or an intervention I see three in this sector maybe we'll start in this section first and if you could identify yourself and also if I could ask you to keep your intervention brief we'll take a number of them so that we can have time my first question is to Mr Pascal you mentioned about Thailand not being ready for the transition period correct so do you think it's fair because you don't have any panellists from Ministry of Health is there any people representing the Ministry of Health of Thailand to say whether they are ready or not that you mentioned that they are not ready for the transition period thank you and could we ask you could you identify yourself I'm Dr Naseer from the Ministry of Health Malaysia my name is Sonal Mata and I'm from the Ministry of Health of Thailand and my question is to the representative of Global Fund they used to be a reference of people who need services and it seems more and more there is a dialogue of country in Global Fund if Thailand is ready to take if India is ready to take who is Thailand and who is India often it ends up becoming government and I think people who really need services have human rights and gone other days of people who require services and I would want to really listen to the response of Global Fund representative and I understand that as a funding mechanism there is a limitation but I really want to know that how is Global Fund making sure that when they mean India or Thailand they mean people we'll take two more and then we'll turn to the panellists and then we'll turn to the international reduction network and my question actually to the Global Fund as we see from Pascal presentation and from all our experience transition plan as it is just a document doesn't work and we all suggest to have like the serious attention to the transitioning the same as a governance in the Global Fund with the all regulation of the strategic view and we all understand that now the Global Fund is a process of developing the strategy and do you have serious understand like I understand that you have this understanding but do you have the serious intention to think over the investment in transitioning because the regular grants with the services they are not investing in the transitioning in the Global Fund to change the governmental systems. Thank you. Thanks one more there and then we'll turn to the panellists and then we'll come to the next round. I'm Abu from India. The question is for Dr. Sari. I really wanted to appreciate and thanks for his comment that Malaysian government has done a lot of human work. They have not seen as a low problem but they have implemented harm reduction as a human seen a human side. So I just wanted to know and ask him Hepatitis C is a very high problem in Malaysia. So when the government is going to see as a human problem because you said you don't have a guideline or whatever. Let's stop there. I see questions and other parts of the room but let's at least take this first round and maybe Marika you since I think most of the questions went to why don't you start. Thank you and both very good questions and not easy ones and I will try to do my very best. So the government decides to transition what happens to the people that is indeed a concern. And just moving forward and that's maybe let's first start with the question from Eurasian Harm Reduction Network. We really see transition planning as a long term process. It really requires working with all stakeholders at country level to work on just defining what this transition looked like and that requires time. And I think the most important part of this given itself is very rush transition. So in most countries I would assume this would take a longer time and as I said as our board is developing next strategy sustainability and transition planning will be a key component already. The team dealing with Eastern Europe and Central Asia with some of these countries will have the global fund initially to pick up all programs how the global fund focusing on key population activities and building the conditions for transition like for example establishing legal frameworks that allow government to fund civil society by building capacitive civil society organizations by establishing systems of community monitoring and accountability. So those are the sort of steps when it comes then to governments like Thailand or India deciding that they will be themselves of global funding and want to fund their own response. That's basically sort of following a similar process even though in the case of Thailand that has been a very rush process what has happened in the case of Thailand and by no means I'm claiming that this is successful. It's an ideal recipe for a strong government commitment. Work is going on a transition plan as far as I know the latest information I got Pascal that the plan is still sort of being developed and part of it because the government under its national health program and insurance it can cover quite a range of activities but specifically activities targeting key populations and even more specifically like NSP and OST programs targeting people who inject drugs are not part of that and what I understood and I understand to be corrected but I can follow up with the team was that the government was submitting a specific budget to cabinet which would be discussed this month with a budget for exactly those activities and that's something we'll be following closely because what I said before any transition in Thailand that does not include NSP OST programs is going to fail and Thailand will not be able to end AIDS. At the same time a budget has been implemented and I would assume this would be a similar approach to other countries to then support civil society in the transition process and also a power civil society to oversee but also there it becomes clear from Pascal that that process is not fully inclusive and that people inject drugs do not feel part of that monitoring mechanism so that's something we have to look at and see how we can remedy. For India we've been discussing the global fund contribution to India and the health budget in India is very minimal and so we're discussing with the Indian CCM now how it can be more meaningful and what added value of the global fund contribution would be and some of the thinking is that we could focus our funding to some of the poorest and most affected states and focus specifically in key populations assuming that the Indian government will take on the overall programming and then over time work with the Indian government and civil society to see to what extent the Indian government is prepared to take over but also I just don't want to give the impression that these are easy processes we know there's many countries that their political commitment is lacking. We've seen the Russian Federation with the global fund proved an exceptional extension to an exceptional approval of some civil society which is very important for people who inject drugs. It's small, it's less than a drop in the ocean and we have absolutely zero leverage with Russian authorities to change their policies and I'm not very optimistic that that will change. To the question of fairness and the absence of the Ministry of Health of Thailand let me just first ask is there anyone in the room from the Ministry of Health of Thailand who feels able to speak to this question? I just wanted to make sure that we gave an opportunity in case someone was sitting there feeling that. Pascal, is it fair? I think the Ministry of Health of Thailand has been involved in this transition and in harm reduction for a long time so it's not like the Ministry of Health is not involved, not participating or not supportive. The Ministry of Health is heavily involved in the CCM and in helping prepare those plans that are the transition plans. We have engaged and provided some support for harm reduction again channeled through the CCM and through the global fund grants. The Ministry of Health has been involved in deploying and developing the previous national harm reduction policy that expired earlier this last month. I think the key issue is that the Ministry of Health I think there's an expectation from civil society that the Ministry of Health will provide more leadership on health-related issues as they affect people who use drugs. As of now, the leadership on drug-related issues remains with law enforcement, with drug control, with public security. I think that's where the key issue is. And Dr. Shari, you say you think about people who inject drugs from the human perspective. What about hepatitis C? Thank you for the questions. We draft a policy on harm reduction. We already include the approach able to reduce blood-borne diseases including hepatitis C. That's why person who comes from the program, part and parcel of the packages given is screening of hepatitis C. And it shows that the numbers of hepatitis C are prevalent among people who inject drugs. And in terms of treatment, your concern is treatment. In terms of treatment, this is the first time in the world that even the developed country, rich country, not afford to buy the drugs. So you can't imagine the middle income country like Malaysia try also to part and parcel the drug into our services. It's very difficult. I throw back to all of you, to think it for them. It's your role to negotiate and go back to every country. Develop country, poor country, middle income country, get united, pressure the pharmaceutical company to bring down the price. I don't think the government not willing to provide the services. It's on you. It's not on the government. I wish all of you. I throw back to all of you. I hope in the future the pressure the pharmaceutical company may or may not bring the price down and everybody going to buy the product out. Thank you. Let me say there are several sessions on hepatitis C treatment and access. And I hope that we can continue this discussion. Let me also say that many of us had been inspired by Malaysia's government's willingness to press for things like compulsory and that we will be looking to Malaysia to set the same kind of example for treatment on hepatitis C that you have on harm reduction and not to have a situation where people have to pay $87,000 in a private clinic in Malaysia for treatment. Let me take some more questions. I know that there were some in the center. Could you please raise your hand again if you have questions? I see one here in the front, there in the back. Hi, good morning everyone. I'm Kasia Malinoska from Open Society Foundations. This is a question in response to a comment by the Dutch AIDS Ambassador but really a question to all of the panelists. In terms of funding properly harm reduction in 2020, the goal that HR Harm Reduction International has set for all of us, I think a very worthy goal. I think a discussion which says that we're framing harm reduction versus criminal justice expenditures is not a helpful way to think about this because if one looks at the national health policies across the world, drugs policies across the world, what you will see now is that there are usually three or four pillars that all governments are committing themselves to. So it's not something that we are bringing to the table as new, it's not about setting one against the other. But I think when you look at the budgets, what you will see is that you usually have two or three pillars that are very well funded and then one toothpick which is health or drug treatment or however we look at health responses to drugs. So I think the ask here is to sort of legitimately follow with budgets commitments that countries have for most part already made and are not living up to. So as I interpret that ask, it's about sort of transparency, it's about following through on commitments that are made at the national level rather than setting one sort of budget and one ask against the other. And so I think if we can think about going into Angus with that framing, which is, you know, live up to whatever you have on paper, then I think that maybe is slightly less contagious and more likely to occur. Thank you. Here on the front and then there on the side. This is a question for Lambert actually. You said that the Dutch government is against legalization. Could you tell me why the most sensible nation on earth is against legalization? Okay, and one more here and then I want to make sure that panelists have the time to respond. Oh, we'll take two more and then we have a slight technical problem. Thank you. I'm from Malaysia. I'd like to maybe just make a comment and maybe a question to Dr. Shari as well. With harm reduction, I think a lot of the effort from the Ministry of Health has been on HIV and AIDS, but it's more than HIV and AIDS. We have patients who are on treatment, get caught by police, put in lockup, no treatment, lose their jobs, lose their stability, go back to drugs. And I think the drug laws haven't been changed. I mean, there's a lot of maneuvering for HIV AIDS, but what do you do about human rights? What do you do about other things that are also part of harm reduction? And it's finally going to stop when we reach zero with IV drug use and HIV. Thank you. Last question here and then. Thanks, Daniel. My name is Razif Kaafle. I'm from Nepal and I'm representing the global network of people doing HIV, GNP+. My question is to Maraike, why do we call you global fund now when you are not global and you don't fund most of the half global? Okay. We have six minutes and actually maybe I'll start with Lambert. Why don't you support legalization? Yeah. Thank you very much for the question. I agree with you. There's so much money spent on law enforcement and if you look at the UNGAS, I don't know yet, but I think we will globally see two different regional blocks. Latin America at the moment, very vocal and Europe on reducing spending on law enforcement and at least emphasizing the importance of harm reduction programs whereas other regions in the world are still very much focused on law enforcement. I think it would be helpful to have a discussion on criminalization versus decriminalization. Decriminalization in the Netherlands and in many other countries does not lead to higher consumption levels. Let's think about that. So what is the value of decriminalization? It does pay off decriminalization. It's an economic argument which of course much more important is also a health argument. In our system in the Netherlands, we have less mortality, less overdoses. People are more healthy and people, I mean, the impact on society of people who inject drugs is much less visible than in other countries without harm reduction programs. Let's have a discussion about that. And so I don't only want to have a discussion about law enforcement and its costs, but also a discussion about the effect of criminalization on society in terms of costs. Now, drugs in the Netherlands are illegal, but prosecution in the Netherlands is only limited to dealing and to production. So drug use in the Netherlands is not illegal. This is a clear distinction we make and it's not always easy to explain, you know, maybe the difference we have, we make between hard drugs and soft drugs on soft drugs, actually it's easy. You can legally buy a limited amount of soft drugs and use it. Possession is not legal but it's a bit complicated. So there's a way we have managed to deal with it. The Amsterdam coffee shops, where you don't buy coffee but where you can buy cannabis are of course a well-known example of our pragmatic approach to this. From a health perspective, we started with our harm reduction programs because of hepatitis C in the early 80s, sorry, B in the early 80s. And actually we even started with methadone programs already in the 70s. And I have to be honest, we were not very successful with that. So it took us 35 years to have working, fully working harm reduction programs. We were criticized by many countries and yes, we did fail in the beginning because we didn't get ourselves well organized. There are so many different government and non-government agencies involved and it really took time for us to get everyone on board. And a very basic lesson learned for us is that harm reduction is a bottom-up approach. As a government, we are not very good at introducing innovative harm reduction responses. No, it's up to people, it's a people-centered approach, it's a human rights approach. And it took us a while as a government as well to understand that and to apply that into our own policies. So Marika, why do you call yourself the global fund if you're not global and you don't fund? Yeah, no, great question. But first to support Lombard and on criminalizing drugs, I think also in the Netherlands what we saw that if you want to do that, it should be more like a global effort. It's really difficult for one country to decriminalize drugs if all the countries in the neighborhood do not do that. And the Netherlands was, this when I was in Lombard's shoes, we always got burned down by this, what's his name, this horrible narcotic board organization in Vienna that's basing its work on the, an agreement from the 50s and still thinks it's relevant. And so it's, I'm not a diplomat anymore as I can say these things now. And so it's really difficult, I think if you read all the sort of the former heads of state who now are in the commission on drugs, whatever it's called, and now come up with really wise advice that drugs should be decriminalized because most of the problems related to drugs are part, are results of the criminalization. But that should be done on a global scale and I would hope we would get there but not very optimistic. Then the global fund, why we do call ourselves a global fund, we're a pretty global still. We support programs in 120 countries and if you would add the countries that are not directly eligible but part of some sort of regional effort it's up to 140 so that's quite a lot. We support countries, the countries that can apply for support for the global fund are all those that are low income, low middle income and for those upper middle income countries of high disease burden which in the case of concentrated epidemics means that there's prevalence of over 5% in any one of the key populations so that's still pretty wide. And to be very clear, and I know there's always lots of rumors going on, the global fund will not pull out of middle income countries. What is a fact is as countries move into high income status and we know with the level of economic growth in big parts of the world, there will be a number of countries that are currently receiving funding from the global fund, they'll move into high income status. That's quite a clear cut off point because if you would start supporting programs in high income countries, we definitely will be more global, we do also have to start moving some of these programs in the United States that have really crappy policies on people who are on drug drugs so I don't think that would be the best use of money. It's also very clear that domestic funding needs to go up and especially in countries at higher income level, it's really no excuse for countries that have the money but refuse to spend the money to do that so we should push collectively pressure on those countries. And also in the current situation, what we call in global fund terminology banned four countries which are the countries that at higher income level with low disease burden have been protected so this of the global disease burden like 2.3% and receive close to 7% of the funding that is likely to change even at the global government, the board is discussing that but it also was based on some sort of a false assumption that key population issues and human rights issues are concentrated in upper middle income countries. I think as we have better data and as we are more aware of these issues, key population issues and human rights violations occur all over the world whether it's upper middle income or low income countries so there's really not a strong justification to protect the upper middle income country growth because of that argument. So much more to discuss on that because of course we are particularly focused on people who use drugs and also that disease burden is not the only gauge of need because there's prevention need also but we'll save that for another time Pascal, a very quick comment from you on this the law enforcement versus harm reduction must we choose and then I'll give the last word to Dr. Shari. I'll just talk briefly about my experience in Thailand under the champion IDU project. The context in Thailand obviously war on drugs, we're raging for more than 10 years now. Our staff, our project workers were regularly arrested 2 to 12 per month over a 66 month period so our entire workforce was essentially arrested at least twice. We had to hire, we hired a senior Thai police officer who I believe is actually in this room. It was Dr. Lieutenant Colonel Kisanapong Putaku. He's here in the room I believe and he was instrumental, that partnership of hiring a senior Thai police officer to work with us and advocate when there were issues in the field to work with us and advocate directly to his peers as police officers and explain why our project was operating, how it was operating, what support we needed, was very effective in reducing some of the negative consequences of engaging with law enforcement. Unfortunately in the transition, that component was cut, it was even described by a senior global fund official as ancillary, a secondary, not very useful mechanism for us and that we should concentrate on meeting our targets. In that context, I think our law enforcement approach was very successful, we documented it. I think some of you might have seen this report online, otherwise there might be some copies still at the booth and I suggest you pick one up but my also colleague Kun Noi who's sitting in the front, Kun Vera Pan, will be presenting in the next session about the successes of our project including perhaps some of the lessons learned from engagement with law enforcement. So that's a good transition to the question to Dr. Sari, it's not just about HIV targets, it's about bigger picture and are you missing it? Before that I'll ask and need to answer the question by Phillips. On the harm deduction, so for information that we have police officers in various levels of task force at the national level, provincial level and district level. For information also, part and parcel to be a police officer, you must pass exam and part of the exam is on harm deduction and the police department met and module on harm deduction to train their people, means that they try to assure that their people did understand on harm deduction and for information, anybody or the people who use drugs when they join the harm deduction program, this is not the license to get the immunity. No, if you do it something wrong, they will catch you because police officers have to admit that anybody made a complaint or report to the police department for the misbehaviour, they must act action on that. For information, once the people who are on harm deduction and being caught by the police and put in lock up, our officers and even the audits officer will go to the police officer, what's wrong with the person here? And to reduce that kind of phenomena, yesterday we discussed the deputy director general, anybody on harm deduction program or the needle exchange program or methadone program will be given a special card. Currently for the needle exchange program, you go to the my officers here, there's a bar code there. Khalid, I don't have a bar code? There's a bar code. So we can now detect who are these people on needle exchange program. Later on, we try to extend to the methadone program because this is the way that we try to inform the public that these people are on recovery process. These are the people on the healthcare management. And for information being recognized by the government, the harm deduction program able to reduce crime in this country. We have Dr. Roshiti Pat and members of the National Lab on crime deduction, it being recognized that harm deduction is part and parcel of the process in reducing crime. And I urge other country, if you are not doing so, if the crime is there, please join us in harm deduction program. And furthermore, I wish everybody that this is the cheapest model, the cheapest investment, but give a maximum impact for those among people who use that. Thank you. So many of the themes that we have talked about will be touched on elsewhere in the conference. I also want to commend to people's attention stoptheharm.org, which is a collective platform that's building toward the un-gas that talks about harm reduction, funding, also drug policy, regulation, et cetera. And I hope you will join me all in thanking our panelists, both for your willingness to support harm reduction and to take the hard questions about it. Thank you.