By Kartlos Kankadze, Mariia Dolynska, and Viktoriia Gultai
The theme of World TB Day this year, "Unite to End TB," reflects the World Health Organization's (WHO's) End TB Strategy, which recently replaced the Stop TB Strategy and corresponds to the UN Sustainable Development Goals (SDGs). End TB sets an ambitious agenda between now and 2035, targeting a 95 percent reduction in number of TB-related deaths, 90 percent reduction in TB incidence rate, and zero families facing catastrophic costs due to TB. Here in Ukraine, our USAID Strengthening Tuberculosis Control in Ukraine (STbCU) project team wonders: What will it take to achieve these ambitious goals in one of Europe's most populous countries, where TB has been a persistent public health concern for many years?
Is End TB possible in Ukraine?
Recently, Ukraine has made some critical advancements on the path to ending TB. For example, with WHO, USAID, and other donors, Ukraine's National TB Control Program has updated its clinical protocols on TB and TB/HIV, institutionalized primary health care involvement in TB case detection and treatment, and revised national and regional policies. TB laboratories implementing WHO-recommended external quality assurance have proliferated and are now contributing to more effective TB treatment in many areas. Ukraine has also taken a major step forward in continual medical education by building its first distance learning platform for TB-related issues. Our STbCU team, along with local NGOs under grants, have contributed to all these improvements, and we continue to push for positive change.
Yet the TB-related Millennium Development Goals were not achieved in Ukraine. Today, the TB-related death rate is almost six times higher than the target (at 12.2 cases per 100,000 people), the TB incidence rate is 1.5 times higher (58.8 cases per 100,000 people), and the TB prevalence rate is nearly three times higher (at 90.2 cases per 100,000 people). We strongly believe that Ukraine can achieve the Stop TB goals despite the challenges. Countries like Latvia have already made great progress. To do so, it needs to follow such countries and continue to move beyond Soviet-era attitudes and practices related to TB while adopting new technologies. More specifically, we consider these to be the most important actions Ukraine and donors can take to end TB:
1. Shift to a new paradigm of TB treatment based on WHO standards
Soviet-era approaches are no longer adequate to address the challenges Ukraine faces like multi-drug-resistent TB, TB/HIV co-infections, outdated health infrastructure, and a lack of trained staff, equipment, motivation, and monitoring. Evidence-based, WHO-recommended practices should be introduced and scaled. For this to happen, it is important to address the habit of relying on personal experience or conventional wisdom rather than on data that prove the effectiveness of new approaches.
2. Push for reform in key aspects of treatment
The Ministry of Health should involve other government stakeholders to push together in these principle directions:
- Prioritize of outpatient treatment. The excessive duration of inpatient treatment (3-6 months) for TB is part of the Soviet legacy. Outpatient treatment is cheaper and more convenient for patients. The outpatient treatment is vital for Ukraine also due to poor condition of the most TB hospitals, which leads to TB transmission inside.
- Involve primary health care institutions in TB detection and treatment. Until recently, only special TB facilities dealt with TB. This approach is changing to make TB services closer to patients and should continue to change.
- Fund socio-psychological support for TB patients. Such support is especially important for patients who are in difficult life circumstances, whose low adherence to treatment jeopardizes their health.
3. Encourage community involvment in supporting TB victims
Community involvement by activitists and TB survivors is important at all levels: from advocating patients’ rights, to reducing stigma and discrimination, to providing socio-psychological support.
4. Target technical assistance at the most vulnerable points
Sharing international experience, scaling up world’s best practices, introducing new technologies, and supporting structural reforms – in all of these areas there is a huge need for continued technical support and expertise from the global development community.
Encouraging Results in Latvia
Latvia is a good example for Ukraine. It had the same heavy heritage from the Soviet Union, the same approaches to TB treatmen, and a similar hospital infrastructure that did not comply with infection control rules.
However, due to strong political will and a flexible system of reasonable planning, Latvia managed to reform its health practices to involve primary health care in TB case management, introduce outpatient TB treatment, create a sustainable state system of social support for TB patients, and update TB hospital infrastructure in accordance to modern infection control requirements.
As result, Latvia cut its multi-drug-resistent TB level nearly in half, from about 15 percent among new TB cases in 2002 to 8.2 percent in 2014.
Will Ukraine be able to end TB? We believe with all our hearts that it can if it mobilizes its political will and learns from the experience of the international community.
Kartlos Kankadze, Mariia Dolynska, and Viktoriia Gultai work on the USAID Strengthening Tuberculosis Control in Ukraine project. Kartlos is chief of party, Mariia is a health management specialist, and Viktoriia is a communications specialist.