Improving Access to HIV Services for Mobile and Migrant populations in the Caribbean ( Regionale HIV/AIDS Bekämpfung

1. Improving Access to HIV Services for Mobile and Migrant populations in the Caribbean(Regionale HIV/AIDS Bekämpfung in der Karibik) Component 2 National Consultancy forSURINAMETo assess the feasibility of the Health Financing Instruments/ Mechanisms, proposed by the Regional Consultant, for improving access to HIV health services for mobile & migrant populations Consultant: Satcha Jabbar Presented by: Raphael Barrett for the 2nd RAG Workshop – Port Of Spain, June 2012

2. Background • Suriname, on the north coast of South America, covers an area of 164,000 km² • 80% of the population (520,000) lives on the coast and the remainder, predominantly indigenous people, Maroons and undocumented Brazilians, live in the interior which is 80% of the area • main economic activities – mining, oil, rice • unregulated, informal small scale gold mining industry employs some 40,000 persons • organising this sector is difficult as it impacts the rights of indigenous & tribal peoples, land right, feuds etc • stricter mining and environmental laws in Brazil resulted in an influx of Brazilian garimpeiros (gold diggers)

3. Map Legend: yellow indicates the small scale gold mining areas Source: Internet

4. Target Population In a Project Meeting held at the National AIDS Program Office of Suriname on the September 20, 2011, the target population was defined thus: Mobile and migrant populations in Suriname will refer to those groups of persons working in the small scale gold mining areas of Suriname The relevance of this definition is that, up until now, no research into access to health services for this section of the population has been conducted, especially with reference to access to HIV+/AIDS services This definition and description corresponds fully with the situation of the migrant/mobile population in the small scale gold mining areas

5. Populations defined • Mobile populations can be defined as people who move from one place to another, temporarily, seasonally or permanently for voluntary or involuntary reasons with the following vulnerabilities • Men, who are mobile for economic reasons, may engage in unprotected sex with sex-workers, a high-risk behavior. • Female mobile populations may engage in transactional sex and increase their vulnerability to sexual violence placing them at increased risk of HIV+ infectionbut may not be able to access health services due to socio-economic, cultural and linguistic barriers. • Migrant workers refers to persons engaged in a remunerated activity in a State of which he or she is not a national. (UNAIDS) Un-documented persons ,wanting to avoid attracting attention from the authorities, tend to avoid contact with public health services including those for HIV+/AIDS

6. Target population demographics • In general there are about 40-50 CSW per 2000 gold-workers • In the Benzdorp area this average is higher and estimated to be 300 for the 2000 active gold-workers in that village • Everyone is in the age bracket 16/17 – 45 years

7. Gold Mining Work Environment • The gold areas have the highest possible risk on almost every aspect of life – health, safety, security, security of property and ownership. • Mining standards are absent and the environment is severely poisoned with mercury. • Usually medicines are not at hand and people have to travel to Paramaribo to get medical help - an air trip that costs around US$200. • There is great competition amongst the CSW and so they do not like to leave their work area even when they are sick

8. HIV+/AIDS Risk population

9. Project Target Population • Target population excludes Surinamese persons who are eligible for access to State health services free of charge • The Project Target Population for Prevention & Testing services is the non-Surinamese population in the interior – 25,000 persons – chiefly Brazilians • The Project Target Population for Care & Treatment is those persons estimated to be infected: • General population • 1% prevalence rate = 250 persons possibly infected • 2% prevalence rate = 500 persons possibly infected • CSW (estimate) = 110

10. Cost of seeking Care & Treatment The Medical Mission of Suriname (MMS) indicates • Brazilian workers, when sick, go to their clinics where they are treated at cost for SR$75 (US$24). If they cannot pay they are still treated. • For HIV+/AIDS tests they have to fly to Paramaribo and the ticket costs must be paid by the non-Surinamers. • Ticket cost = US$180 • Lab extended test cost = SR$300 (US$90) (test) An extended test is the first test that is required by Internal Medicine when a doctor finds a patient to be HIV+ and has referred them to the hospital. The procedure consists of a blood test and X-rays of the lungs, liver, heart and other vital organs. Sometimes a scan is required. • If Brazilians are registered with the government as residents, they would receive treatment free of charge. But many are “undocumented” and will not do so.

11. Outreach Costs • MMS indicated that they are willing and able to implement an outreach informational programme for the remote areas, since they are already operating there • The Brazilian churches have also indicated their willingness to disseminate information to their members • Budget:

12. Financing Options • The sensitivity regarding all information - production figures, company names, owners of gold mining rights, areas of concession - coming from the Government is a constraining factor • Given this factor, levying a fee on these permits will be difficult and problematic

13. Financing option– Gold Commission • Licensed gold buying companies pay a 1% royalty on the purchases from small scale gold mining companies in addition to a 4-5% fee for overhead costs • It is proposed that a Health Fee of 0.1% of their selling price be collected from the seller through the Tax Department and the funds earmarked for the Ministry of Health for the project objectives • Revenue projections are:

14. Financing option– Mining rights • A Health Fee on the holders of gold exploration rights which currently cost SR$0.10 per hectare per year. • Informal sources at the Ministry of Natural Resources/ Geological Mining Service explained that the requested information is “sensitive” due to the restructuring of the small scale gold mining industry and so no data was provided. • The General Bureau of Statistics has general information to 2009, but there is no distinction between gold and other mining rights. • We are of the view that there is real potential in this segment for imposition of a Health Fee since the holders of mining rights are the direct beneficiaries of the production and should be considered after the dust of restructuring the sector has settled.

15. Financing option– Air Travel; Grants Two other options considered were • A fee on domestic air travel. The problem here is data collection and the management of the system as the Luchtvaartdienst (Office of the Airstrips) “does not process daily arrivals and departures”Furthermore, the carriers are of the opinion that air tickets should not be a vehicle for levying fees to reduce HIV+/AIDS which is the responsibility of the Ministry of Health through general taxes. • The Brazilian Embassy, when asked if they would assist in paying for HIV+/AIDS prevention and treatment for their nationals, responded that Brazilians who want health care should not enter Suriname undocumented and should return to Brazil where they are eligible for free medical services.

16. Implementation A strategic approach to engender political and financial support for the project objectives: • Meetings with senior governmentpolicymakers and administrators in the Ministries of Finance, ForeignAffairs and Health to obtainapprovalfor the financingmechanismsproposed. • Because the targetpopulation ispredominantlyBrazilian, thereisreluctance by private institutions and governmentdepartmentsto contribute as thereis a popular perception thatthe Braziliansin Suriname have gold, are undocumented, do not pay taxes, and take all the gold of Suriname abroad. • Emphasis on ‘equalaccessto health’, i.e. UniversalCoverage • There isneed for an indepthstudyto establish the strategies, projects and programs required to reach populations in the interiorwithPrimary and SecondaryHealthcare as well as to determine the costsof transportation, safetyand the adequacyof service deliveryto theseremoteareas.

17. Summary The estimated budget for the coverage proposed is as follows: Doctors visits, testing, care& treatment: US$343,800 Transportation (depends on location): pm Outreach: US$ 4,160 Subtotal US$347,960 Unforeseen 10% US$ 34,796 Total without transportation costs US$382,756