Access to needle and syringe exchange services in Estonia presented by Aljona Kurbatova prepared by Aire Trummal (initially prepared for the workshop How do we know what works? (BZgA, WHO), Berlin, 23.10.2008) 1
Background National HIV and AIDS Strategy 2006-2012. Committee of the Government of the Republic, different ministries, National Institute for Health Development. Epidemic spread of HIV in two regions Tallinn and a county in East-Estonia. Mostly among IDUs. Most of the interventions are targeted at these regions and coordinated through the national level. 2
Background Policy cycle: 1) Forming target plans and standards 2) Monitoring the process of implementation 3) Measuring the quality and outcome of the concrete services 4) Measuring outcome and impact of the national response in the target groups 5) Preparing data for use 3
Syringe exchange, background Population size: 13 800. More than half of the IDU population is HIV infected. In total 30 syringe exchange sites/teams. 19 are outreach teams. 28 locate in Tallinn or East-Estonia. Financed and coordinated through NIHD. Compared to 2003, the amount of visits has multiplied eight times around 170,000 visits in 2008. Little more than 2 million syringes and 700,000 condoms distributed in 2008. Study 2007: 64% of IDUs in Tallinn and 75% in Kohtla- Järve got syringes from SE during last month, 48% in Tallinna and 65% in Kohtla-Järve had SE as the main source for syringes. 4
Target plans and standards NATIONAL STRATEGY: Long term objectives behaviour and HIV-prevalence among IDUs (united effort of different sectors and organisations) ACTIVITY PLAN OF THE STRATEGY 4- year and yearly plan the amount of services targeted at IDUs planned for the whole country (formed by the ministries involved, reviewed by the Government Commission) ACTIVITY PLANS OF SERVICE PROVIDERS IN THE REGION Yearly plan the amount of service planned for each organisation (in cooperation of service providers and NIHD). SERVICE DESCRIPTION the types of services provided, required conditions, safety requirements, etc (in cooperation of service providers and NIHD). 5
Target plans and standards Good practice: One agreed strategy and activity plan for the country. Concrete yearly targets for each service provider. Service descriptions as part of the contracts. Challenges: Lack of indicators for measuring the quality of the service. Lack of agreed professional qualification standards and standardised trainings. Lack of nationally applied service standard. 6
Monitoring implementation SYRINGE EXCHANGE SERVICE PROVIDER Registering the act of service delivery (system agreed between service providers and NIHD) Reporting to NIHD (agreed reporting form stating process indicators) Reporting to the Ministry of Social Affairs (agreed reporting form stating main process indicators) NIHD Monitoring planned versus achieved results Calculating the coverage of syringe exchange Ministry of Social Affairs: reporting to the Government Commission 7
Monitoring implementation Good practice: Agreed system and indicators for registering service delivery. Following planned versus achieved results on yearly bases. Assessments on the coverage of the service (using data on service delivery and study data). 8
Measuring quality and outcome of the service Assessment of changes in the target group after receiving the service (in cooperation of NIHD and service providers). External evaluation of the national response, including syringe exchange service in regions (organised through NIHD). 9
Measuring quality and outcome of the service Good practice: Yearly data collection on IDUs receiving the service starting from 2003. External evaluations of the national response after every 2-3 years. Challenges: Lack of agreed system for reviewing the quality of the service. Lack of data collection on client satisfaction. Lack of qualitative data on accessibility of the service. 10
Measuring outcome and impact in the target group Bio-behavioural study in 2005 and 2007 in two regions (NIHD in cooperation with Tartu University and service providers). Routine registering of new HIV cases (through laboratories and Health Protection Inspectorate). 11
Measuring outcome and impact in the target group Good practice: Repeated data collection on HIV-prevalence in IDU population in main regions. Challenges: Limited data on HIV transmission routes related to the registered cases. 12
Data for use Overviews on the process results and coverage of the service (by NIHD). Study reports on behaviour of SES clients and HIV-prevalence and behaviour of the IDU population (by NIHD). Triangulation of data on process, outcomes and impact (by NIHD). 13
Data for use Good practice: Quite a lot of data sources available on IDUs. Challenges: Little is known about the spread of injecting drug use in other regions beside Tallinn and East-Estonia. Limited data available for answering the question why? Maximum is not taken from the possibility of using data for improved action. 14
The roles NIHD in national level: coordinating the general development of the service, planning the budget and the service need for the country, conducting public procurements financing the service, organising staff trainings, conducting studies, analysing the results of the service Service providers in regional level: planning the service and the budget in their organisation, delivering service to the target group, questioning the clients of SES, participating in preparing service descriptions and in other developments (including preparing the national strategy). Coordination goes directly from the national level to the NGO sector. With some exceptions there is little involvement of the local municipality and county government level. 15
THANK YOU! 16