Ukraine
Ukraine is among the top-priority countries in Europe for improved tuberculosis (TB) control. Ukraine’s estimated TB case rate of 106 cases per 100,000 population is the eighth highest in Europe and Eurasia. According to the World Health Organization’s (WHO’s) Global Tuberculosis Control Report 2008, Ukraine had an estimated 49,308 TB cases in 2006, an increase of 4.6 percent from the previous year. Of these, about 44 percent were cases of sputum smear-positive (SS+) TB.
In 2005, WHO called for redoubled efforts to scale up effective TB control using DOTS (directly observed treatment, short course) throughout the European region. In November 2005, the Ministry of Health (MOH) issued an order adopting DOTS as the basis for national TB control policy. The new National TB Control Program (NTCP) for 2007–2011 now supports rapid expansion of DOTS coverage, with the goal of moving from 29 percent in the USAID-supported pilot regions in 2007 to 100 percent by 2011. Although Ukraine currently reports 100 percent DOTS coverage, the quality of DOTS services requires significant improvement in many areas; at present, only approximately 50 percent of the population has access to quality DOTS.
Intensified measures are needed to contain Ukraine’s growing TB problem, which is exacerbated by increasing cases of multidrug-resistant (MDR) TB and one of the fastest-growing HIV epidemics in the world. According to WHO, nearly 16 percent of new TB patients have MDR-TB, the third highest proportion in the world. ¹ By the beginning of 2008, extensively drug-resistant (XDR) TB was also reported in Ukraine. Both TB and HIV are concentrated in the southern and eastern oblasts (provinces) of the country, and TB-HIV co-infection is a growing challenge. Results of surveillance in 2006 in Donetsk Oblast indicate that 16 percent of TB patients in the civil sector are co-infected with HIV. Among prisoners, nearly 24 percent of TB patients are co-infected. More than 60 percent of AIDS deaths are attributable to TB. While outdated practices still exist, recent policy changes indicate a growing government commitment to improved TB treatment standards and coordination with HIV services.
USAID Approach and Key Activities
Since 2000, USAID has supported the TB control program in Ukraine and is now implementing comprehensive DOTS expansion activities in 10 administrative areas in the country, reaching approximately 50 percent of Ukraine’s population. Between 2000 and 2008, USAID funds for TB programming in Ukraine averaged $1.5 million per year. USAID’s assistance includes the following activities and interventions:
- Facilitating the development of an appropriate legislative base in support of newly introduced TB control approaches and assisting the government with high-quality DOTS expansion to additional oblasts
- Designing, implementing, and building capacity to sustain laboratory quality control procedures for smear microscopy, culture, and drug susceptibility testing
- Introducing and institutionalizing methods to monitor program performance at all health service levels
- Developing a drug supply management system
- Improving the use of program and surveillance data in TB program management and providing information to health care providers, patients, and the public
- Implementing specific community mobilization strategies to increase the awareness and understanding of TB transmission, symptoms, treatment, and cure among the general public as well as among at-risk populations
- Introducing culturally sensitive treatment support strategies for TB patients and their families
- Strengthening provider capacity to diagnose and treat TB based on DOTS, including improving provider knowledge on standardized treatment with patient support, the referral of TB cases, and appropriate counseling and client-provider interaction with populations at risk
- Introducing the Global Plan to Stop TB and Stop TB Strategy approaches to combat the growing challenges of TB-HIV/AIDS co-infection and MDR-TB and XDR-TB
- Expanding activities to the detention and penitentiary systems, where particularly vulnerable populations are located
USAID Program Achievements
Between 2000 and 2008, USAID, in collaboration with national health authorities, supported PATH and WHO to advance implementation of internationally recommended DOTS-based approaches to diagnose and treat TB in 10 administrative areas. USAID’s assistance has contributed to the following improvements in TB control in Ukraine:
- Piloted DOTS in Donetsk Oblast, demonstrating the feasibility of a standardized approach in Ukraine to TB providers unwilling to change outdated practices
- Provided high-profile support to the MOH in developing associated regulatory documents for TB surveillance and laboratory practices, as well as the first DOTS-compliant concept paper and national guidelines to frame a new NTCP for 2007–2011 and prompt TB control reform nationwide
- Reached 70 percent cure rates in Donetsk, resulting in USAID’s transferring management of DOTS-based TB control activities to the regional administration to ensure sustainability
- Expanded high-quality implementation of DOTS in 10 regions, increasing coverage from 6 percent in 2001 to 40 percent in early 2009
- Supported TB activities in the Donetsk Oblast that resulted in a 5.6 percent decrease of TB incidence in 2007 and a 7 percent decline in TB mortality on average annually between 2005 and 2007
- Provided technical assistance (TA) to incorporate TB case detection into primary health care settings and incorporate DOTS training into the curricula of medical institutions for both pre- and in-service training
- Trained 4,000 specialists and 1,062 general practitioners in internationally recognized best practices for TB prevention and control nationwide
- Expanded TB services based on the DOTS strategy to the detention and penitentiary systems
- Introduced laboratory quality control and quality assurance methods in eight oblasts, thus enhancing the functionality of the laboratory network in those regions
- Continued to provide TA for improving sputum smear microscopy results, achieving an overall tenfold improvement in accuracy
- Developed curricula and conducted training to improve communication and relationships between health care providers and their clients, with the goal of increasing treatment completion rates and improving the quality of care experienced by patients
- Established a successful and sustainable model for TB patient support for treatment completion in collaboration with the Ukrainian Red Cross Society
- Improved health information, education, and public awareness campaigns, which more than doubled self-reporting of TB cases to medical facilities
- Strengthened collaboration between TB and HIV/AIDS programs and established oblast-level TB-HIV/AIDS Collaborative Task Forces to review policies and revise existing guidelines to better support programs for co-infected individuals and reduce fragmentation of care
- Improved outreach, peer education, and support for people living with HIV/AIDS to increase TB treatment completion among co-infected individuals
Partnerships
Partnerships are an important element in combating TB in Ukraine. Key USAID partners include PATH, WHO, the World Bank, the MOH, the F.G. Yanovsky Institute of Tuberculosis and Pulmonology of Academy of Medical Sciences of Ukraine, oblast and city authorities in the target regions, the All-Ukrainian Network of People Living with HIV/AIDS, Futures Group International, and numerous local nongovernmental organizations.
1 Data from a regional survey in Donetsk Oblast
February 2009
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