The news came as a shock: all harm reduction programs were terminated this year in Bulgaria, an EU member state. Why? Yuliya Georgieva, a veteran Bulgarian harm reduction activist from the Centre for Humane Policy and the new co-chair of the Eurasian Harm Reduction Association, answered our questions.
Drugreporter: How and why did you get involved in harm reduction?
Yuliya Georgieva: It was in the mid 90s during the heroin epidemic in Bulgaria. Some of my friends already used and my instinct was that I needed to help somehow. Of course, at first I tried to speak with them, to support them, but it didn’t work very well. Then I started to buy some syringes for my closest friends. It was absolutely instinctive behaviour – I hadn’t heard of harm reduction in those days but I felt that this was the right way to do things.
Some time after that I also started to use drugs and in a few years I became one of the first clients of “Initiative for Health” foundation – the first harm reduction organisation in the country. Very soon after that I became a volunteer for the organisation and started to distribute syringes and information for my friends. With a colleague from Initiative for Health we had a joke that I’d opened the first drop-in centre with a safe injecting room in the country in ’97.
So, the guys from the foundation helped me very much and in 2000 I’d quit drugs, started my education in the university, and tried to work for the first Therapeutic Community in the country. Very soon I realised that it was not my cup of tea and quit. In this very hard moment of my life, I received a call from Elena (the director of the foundation) and she offered me a job there.
Bulgaria is the poorest EU member state. Injecting drug use is mostly concentrated in impoverished Roma communities. The EU has spent a lot of money on the integration of Roma people, did it have an impact on their lives?
My opinion is that, unfortunately, the money wasn’t spent in the proper way and instead of improving the quality of life of Roma people, they segregate the community even more. Some of those financial resources were stolen by fake NGOs and some were spent in an improper way.
In that situation, the right wing propaganda pushed very hard for their interests and all the time published fake information about the social benefits for Roma people – claiming that the money for health, education, and social benefits were spent on the Roma community etc. The result is that now we have extremely segregated communities without any contact with health care facilities, with very poor educational possibilities, and with working potentialities only in the black market. It closes the communities off even more and exacerbates the negative attitudes against Roma people among the society.
It was the Global Fund to Fight AIDS, Malaria and Tuberculosis that introduced and funded harm reduction in Bulgaria for 14 years. What progress has Bulgaria made in this period?
In fact, Open Society Foundation introduced Harm reduction in 1997 in Sofia. Before the Global Fund program came to the country, there were already three very good harm reduction organisations, with strong advocacy positions and very good services. The Global Fund program supported those three organisations at first – they provided training for staff members. Some of them became consultants for the Ministry of Health and became part of the Ministry’s working groups. They built the skeleton of the structure.
In 2004 Global Fund’s Ministry of Health National HIV program supported 7 organisations working with people who use drugs in different parts of the country, to start dealing with harm reduction. Part of this programme was newly formed, whilst part was redistributed for the needs of the Global Fund program.
Then came the “golden” era for harm reduction services in the country. There were almost 60 organisations (among all key populations such as people who use drugs, sex workers, men who have sex with men, Roma population, young people etc), there was also a lot of funding for building the capacity of the structures of the Ministry of Health.
Also, during almost the same period the National Centre of Addiction used to work very openly and introduced a lot of best practices – in 1995 the first free substitution programme was opened, whilst the first decree of the Ministry of Health on Harm Reduction was adopted in 2000 – they supported very strongly the Ministry with introducing harm reduction on the national level. And we used to have very good results. Officially Bulgaria still has very low HIV prevalence: 2.8/100 000.
Why and how things did get so bad?
At the same time the bureaucrats from the National HIV program had all the power, all the money, and the political support, and day by day they built a “one man show” – making decisions without involving independent NGOs and community representatives. They made a lot of wrong or inadequate decisions regarding the everyday work; usually the financial tranches to NGOs were late by 4-5 months and the teams needed to work without salaries for long time periods. The NGOs were pushed out of the real decision making and were put in the position of “sub-contractors”, who didn’t have the freedom to explain their positions strongly and to fight for the interests of the target groups. If the NGOs wanted to work for the MoH program, they needed to be obedient and to execute the ministry’s orders.
All those organisations became very dependent on the Ministry of Health and stopped adhering to one of the main functions of Harm Reduction – the advocacy for better policy and independent existence. Day by day the compromises became a systematic part of the functioning of the organisations and most of them became part of the bureaucratic hierarchy of Ministry of Health.
Watch our video we produced in 2012 about harm reduction in Bulgaria!
Now that the Global Fund has left the country, it is up to the national government to ensure funding and support for harm reduction programs. How is it performing its duties?
All Harm Reduction services closed in July 2017 after Global Fund withdrew. The transition plan which was required from Global Fund was prepared in a very non-transparent way and wasn’t even really started once Global Fund withdrew. In the autumn of 2017 the MoH initialised some field testing for HIV through Regional Health Inspectorates but didn’t even try to make it a ‘good practices’ experience. They’ve just tried to assure the international partners that something happens here, rather than try to do a proper job.
In November 2017 the Ministry of Health launched a call for applications in the field of HIV prevention among the key populations in 13 different towns and cities. The requirements of the procurement were so ridiculous that almost no one applied and two organisations decided to stop the procedure after they win the contract. One of the requirements for the service providers was to provide the entire amount of money needed to perform the activities in advance, in the Ministry of Health bank account, as a guarantee that they will not steal the money. Also NGOs weren’t allowed to use the consumables they already had (or to look for donations) and all needles, syringes etc needed to be bought in the framework of this proposal. The amount was about €166,000 for all 13 areas.
So why did they launch a call for applications if NGOs are not able to apply?
Again, it seemed like that call for grant applications was opened not to ensure adequate services but to show a willingness to deal with the problem in front of the International partners – GF, EU, WHO etc. – and also to show that the Bulgarian NGOs don’t have the capacity to work within the national funding rules. A few days ago (on the 22nd of November 2018) new public procurement calls for outreach services in 4 cities were opened for 2019. This time the requirements seem much more reasonable and I hope that more colleagues will have a chance to apply. Unfortunately, the public procurement mechanism is extremely rigid and very slow and even if the concourse pass without any appeals (which will stop it), it will take more than half a year to start a real job. This means that all key populations will stay without any services for about two years, which means that the possibility of a hidden HIV epidemic grows every day.
Bulgaria urgently needs a far more open procedure for opening calls for NGOs which will guarantee the continuity of the services, will open the system for more NGOs with different models of working, and which will guarantee better services and better experts in the field, dealing with modern and successful methods.
How did the harm reduction NGOs respond to the lack of funding? Can they continue services or choose alternative survival strategies?
All NGOs stopped working with HIV prevention. Some of the colleagues tried to do some outreach voluntarily, during their TB obligations, but most just closed their activities with the HIV key populations and switched to different activities – school prevention, migrants, trafficking etc.
What about the consequences of the lack of harm reduction? Do you see changes in infections and overdose deaths?
I don’t think that anyone knows what is happening out of sight. There isn’t any testing, needles, or case management among the most vulnerable populations and no one can even imagine the results of this. Unofficially, my colleagues told me that during one of the last testing campaigns last year there were 5 new cases from 30 tests among PWUD. They didn’t become part of the official statistics because the case management was already officially closed and they weren’t able to deal with confirmatory tests alone.
I really hope that information is wrong but it sounds very possible.
The European Union has a progressive Action Plan on Drugs, supporting harm reduction. Does it make any difference in Bulgaria? Could EU institutions do more to help you?
The last National Drug Strategy expires at the end of 2018. The preparing of the new one started in July but still is not published and adopted. I hope that, as usual, the new one will be a copy-and-paste of the EU strategy and action plan, but there are some concerns around its title. It was promoted as: “National Strategy to Combat Drug Abuse and Illicit Traffic in Narcotic Drugs and Precursors for the Period 2019-2023”. Which doesn’t sounds very harm reduction oriented.
I hope that very soon we will have the chance to understand what path Bulgaria will choose regarding drug use.
EU is the most important partner and opinion maker for the ruling political party (GERB) and its prescriptions are very important for developing good, evidence based practices. I understand that every country has a right to take independent policy decisions, but still think that some instructions, explanations and good practices can guarantee better decisions for the different members. We will need very strong advocacy on behalf of civil society to show our needs to the EU Commission and to persuade them of the importance of these issues. Unfortunately, we don’t have it here, and we need to look for international networking and support.