The reduction of the epidemic of tuberculosis in Ukraine by expanding the access to high-quality services to fight against this disease.

Timeframe: 2011-2015

The 2011 marked the16 years since the epidemic of tuberculosis was announced in Ukraine. Despite the fact that as of 2006 the situation stabilized to a certain extent, tuberculosis remains the most frequent cause of death among patients with infectious diseases.

During many years Ukraine tried to fight against tuberculosis independently, however due to the insufficient financing and control of treatment the problem has not been eliminated. Understanding that this task can not be solved independently, Ukraine since 2006 three times applied for the grant of the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereinafter - GF) [1], and three times the application was rejected. The reasons included non-transparent procedures, common distrust to the country and the situation with introduction of the controlled treatment, taxation of the GF grant etc.

The last (successful) application from our country was submitted for consideration of GF in 2009. It was then announced about the beginning of the 9th round of grants from GF. According to the submitted documents, Ukraine requested the allocation of $103.5 million for five years. The initiators of the application were the Rinat Akhmetov’s Foundation for Development of Ukraine and the Ministry of Health of Ukraine (hereinafter - MOH). In March 2010 the Global Fund agreed to provide Ukraine with the funds to fight TB. And on December 10, 2010 the GF officially signed the Grant Agreement with Ukraine.

The total budget of the Program after the consultation with GF was - $94 862 399
 Year 1 – $4 547 584
 Year 2 – $25 111730
Total for Phase 1 – $29 659 314 (2011-2012)
Total for Phase 2 – $65 203 085 (2013 -2015)

The Principal Recipient of the grant is the Charitable Foundation for Development of Ukraine. This choice was not accidental, because the Foundation has extensive experience in TB control, both at the regional and national levels. The Foundation became the main link, which brought together all the stakeholders: the Ministry of Health, international and community organizations, medical facilities and the penitentiary system. This, in turn, ensured the quality Ukraine’s application and the receipt of funds of the international community.

Main Sub-Recipients of the Program:

• All-Ukrainian Center on TB Control under MOH of Ukraine (www.tbc.gov.ua)

1. Harmonization of the regulations with the international standards 
2. Preparation of:
a. The National Plan of personnel training;
b. The National Plan of laboratory network development;
c. The National Plan of monitoring and reporting (M&R);
d. Maintaining of the register of patients with tuberculosis.

• The State Peniteniary Service of Ukraine (www.kmu.gov.ua/punish/control)

1. Maintaining of the register of patients with tuberculosis; 
2. Optimization of the laboratory network and improvement of diagnostics;
3. Introduction of international standards in the management of patients with tuberculosis

• ICF "International HIV/AIDS Alliance in Ukraine” (www.aidsalliance.org.ua)

1. Purchase of equipment and anti-TB drugs of the 2 line 
2. Development of the order of management of patients wih HIV/ТB

• PATH Ukraine (www.path.org)

1. Training (arrangement of trainings)
2. Participation in the development of regulations
3. Purchase of equipment for the TB register

• Ukrainian Red Cross Society (www.redcross.org.ua)

1. Provision of care to patients at risk who have a tendency to interrupt the treatment

• Labor and Health Social Initiatives (LHSI) (www.lhsi.org.ua) (ACSM: Communication)

• NGO “Intellectual Perspective” (www.csep.org.ua) (ACSM: Advocacy)

• AUCF “Coalition of HIV Service Organizations” (www.hiv.org.ua) (ACSM: Social Mobolozation)

• CF “Foundation for Prevention of Chemical Addictions and AIDS” (www.helpme.com.ua)
The All-Ukrainian TB hotline (0 800 503 0 80)

Partners of the Program:

• The Ministry of Health of Ukraine
• The State Service of Ukraine for combating HIV/AIDS and other socially dangerous diseases
• The National Institute of Tuberculosis and Pulmonology named after F.G. Janowski
• All-Ukrainian Charitable Organization “All-Ukrainian Network of PLWH”

Implementation of Program in the regions:

 • 2011 - Dnepropetrovsk, Donetsk, Kharkov, Lvov, Nikolayev, Kirovograd, Kyiv oblasts and Kyiv city
• 2012 – AR of Crimea, Zaporozhzhya, Luhansk, Odessa, Kherson oblasts and Sevastopol city
• 2013 - Volyn, Zhytomyr, Poltava, Rovno, Sumy, Khmelnytsky, Chernihov, Cherkassy oblasts
• 2014 – Vinnitsa, Zakarpattya, Ivano-Frankovsk, Ternopol, Chernovtsi oblasts.

During the 5 years the Program will provide assistance and support to all oblasts of Ukraine.

The main objective of the application is the reduction of the spread of tuberculosis in Ukraine and the subsequent termination of the epidemic. This can be achieved by expanding and improving the access to quality services on prevention and treatment of tuberculosis (hereinafter – TB).

It is important to note once again that earlier this sphere was always underfunded. Although from the beginning of the 2000s, Ukraine tried to follow the international strategies to combat tuberculosis, it did not bring the desired effect [2]. As a result, the vulnerable and poor population groups suffered most from TB. This project shall provide an opportunity to support all the initiatives for which the state traditionally lacked money. They include treatment under the direct observation of health workers (DOT-treatment), establishment of the register of patients, and, most importantly, provision of the timely diagnosis and treatment for the most vulnerable population groups. In addition, due to the mechanisms of the Program the patients shall be able to feel the psychological support of the society, and hence - to have more energy for healing.

The program includes the following objecives:

1. To improve the diagnosis of TB by optimizing the network of laboratories in the community and prison settings.

Within this objective the laboratories’ performance in the diagnosis of tuberculosis shall improve. For this the labs shall be provided with all the necessary equipment and consolidated into a national network. This will help not only to control the quality of services, but also to quickly identify and correct possible gaps.

2. To improve the access to quality services for people who for various reasons have limited access to anti-TB health care. 

Within this objective there are three areas of activity. First of all, it is the “geographical” expansion of the Program. The access to diagnosis and treatment of TB shall be available even in remote villages, and where necessary, at home.

Secondly, the treatment of MDR TB shall be expanded. It shall be provided in 15 oblasts of Ukraine with the highest level of TB in line with the international standards. For 5 years of the Program it is planned to provide treatment to 5560 patients.

Thirdly, the treatment of TB patients with HIV/AIDS shall be enhanced. For this the active measures on prevention of HIV/AIDS spread in TB facilities, as well as mass screening of patients for HIV shall be ensured.

3. To increase the capacity of the health care system in Ukraine to combat TB through the improved management (leadership, monitoring and evaluation, human resource development), which is necessary for the successful implementation of the Program to fight TB. 

The Program envisages activities on the training of managers of TB programs at the national and regional levels, as well as organization of anti-TB conferences. Moreover, in the regions of Ukraine the scheme for collecting the information on the spread of TB shall be improved. In 43 Ukrainian universities the curricula shall be revised in order to ensure the future doctors to pay more attention to the treatment of tuberculosis and, more importantly, to get the necessary knowledge and skills. Also in Ukraine the National Plan for Prevention and Treatment of TB shall be developed in order to coordinate he follow-up in this area.

4. To improve the overall access to diagnosis, treatment and care of TB by raising awareness, mobilizing political support and reducing stigma and discrimination.
The fourth objective of the Program envisages raizing awareness of the public at large on the prevention and treatment of TB. Our goal is not only to inform the public on the plan for the diagnosis of TB, but also to support the patients and facilitate their integration into society. Because only together we can overcome the epidemic, of which anyone could become a victim, regardless of material status and attitudes.

NOTES:

[1] The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the major international institutions, which finances projects aimed at combating the three dangerous diseases. The decision to establish the Fund was made at the UN General Assembly Special Session on HIV/AIDS in 2001. The Fund was established in early 2002 and since then it annually awards grants to countries that most need support in the fight against the given epidemics.

The distribution of grants is carried out in the format of “rounds” - the so-called phases of funds allocation. In 2002 all countries could apply for participation in the first round of the Global Fund and in 2012 the winners of the 11th round shall receive the grants. In 2010, the winners of the 9th round were announced, among which was Ukraine. In general, during its existence the Global Fund has allocated 22.4 billion USD to 150 countries to support programs to control the above three diseases.

[2] World Health Organization (WHO) has developed the guidelines for TB control - DOTS. The name comes from the English acronym DOTS - Directly Observed Treatment, Short-Course, which means “directly observed treatment, provided in short courses”.

The DOTS program includes 5 main directions:
1) improvement of legislation to control TB;
2) improvement of laboratories’ performance to better detect TB;
3) standardized treatment of patients under the constant observation of health workers;
4) effective system of drug supply;
5) monitoring and evaluation of the Program.

DOTS is the foundation of the global strategy “Stop TB”, which was also developed by WHO. Its purpose is to substantially reduce the global TB epidemic by 2015 by ensuring for all TB patients a universal access to high-quality diagnosis and patient-oriented treatment.

In Ukraine, the pilot DOTS programs were implemented in 2001. Then the Government took important steps to reorient the TB control system in accordance with the international standards. At the moment the DOTS strategy is fully adopted in Ukraine. It is the basis of the “State Program on combating tuberculosis for 2007-2011” for the implementation of which the state budget allocated $241.7 million.

However, the Program ends this year, and Ukraine should adopt a new road map to combat tuberculosis. In the first quarter of this year, national experts following the initiative of the Ministry of Health developed a Draft Concept and the draft “National targeted social program on combating tuberculosis in Ukraine for 2012-2016 years” (hereinafter - the Program).

These documents were prepared without public participation. Therefore, the Rinat Akhmetov’s Foundation for Development of Ukraine provided technical assistance in finalizing the Concept and the Program in view of all international requirements.

Currently, the draft Program has been prepared for approval of the relevant ministries and agencies.