Yearly Archives: 2017

Health in the Soviet Union and in the post-Soviet space: from utopia to collapse and arduous recovery

September 30, 2017, The Lancet

“At least in those days, I had no rent and no heating bill to pay, I had free access to doctors, and the state would make sure my children are educated and in good health”, says Evguenia, a babouchka I spoke with recently in Moscow.

Health is one of the areas where nostalgia for the Soviet Union is still common among Russians and people living in countries in the post-Soviet space. Most Russian adults alive today witnessed the dramatic deterioration of health care in the 10 years after the end of the Soviet Union. These people have seen the social safety net provided by the Soviet system abruptly disintegrate, inequities grow sharply, and elderly, sick, and disabled people become left behind while the country painfully and erratically transitioned from a planned economy to capitalism. Another reason for the lingering nostalgia is the persistent perception that health care should be provided by the central government, with little or no responsibility on the part of the individual.

The Soviet Constitution of 1936 stated that citizens of the Soviet Union have the right to health protection ensured by free, qualified medical care in state institutions. In the years after the 1917 revolution, Russia created a centralised and integrated state health-care system based on concepts introduced by Nicolaï Semashko, the People’s Commissar for Public Health from 1918 to 1930. The health-care system relied on an extensive network of primary care clinics and specialised hospitals staffed by large numbers of doctors and health-care workers, and it provided universal coverage, accessible to everyone, even in the most remote parts of the country. The improvements in health care during the first half of the 20th century were quite remarkable, with life expectancy in the Soviet Union in the 1960s similar to that in the USA.

However, the system rapidly deteriorated in the 1970s. Reduced funding from the central government and increasing bureaucratic and economic inefficiencies resulted in inadequate availability of medical drugs and technologies, poorly maintained facilities, worsening quality of health care, and falling life expectancy.

The transition of health systems from the Soviet facility-based model to patient-centered and decentralised standards of care is far from complete. Throughout the region, national funding allocations are based on number of doctors and beds (rather than on outputs). For example, tuberculosis care in many countries in the post-Soviet space is still provided through a hospital-centric system, where patients are admitted to hospital for standard tuberculosis treatment; not only is this system costly and inefficient, it has contributed profoundly to the rapid increase in the incidence of multidrug-resistant tuberculosis in the region. Public health budgets barely cover the salaries of health-care staff. Drugs are often paid for out of pocket, and bribes are often a way to access better quality service. The private health insurance market is expanding among urban middle-class employees as this population increasingly turns to private health-care networks.

Another key feature of health care in the post-Soviet context has been the dominance of treatment and curative approaches, with little focus on prevention and public health. The fast spread of the HIV epidemic in the region is attributable in part to this vertical, provider-centred, treatment-oriented system with almost no cooperation with the non-governmental sector and grossly inadequate attention to prevention.

Nevertheless, there are also reasons to believe that change is possible, even in the face of the tremendous health challenges in the region. But change is down a long and arduous road. The many sources of resistance include health-care professionals themselves, corrupted intermediaries who have been taking advantage of the system, and political elites who are reluctant to change structures they have benefitted from, directly or indirectly. This is well illustrated by the bitterness that prevails with respect to the current efforts of the Ukrainian Government to achieve radical public health reforms in the country. Some enlightened politicians and health professionals do recognise that the current system is both ineffective and unsustainable, and that health outcomes in the region are falling behind the rest of the world. Ordinary people are beginning to recognise that the Soviet model no longer understands or serves their health needs.

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Remarks given at the 40th Programme Coordinating Board meeting of UNAIDS in Geneva, June 27,  2017

Thank you Mr Chair.

Thank you Michel for your report and contextual analysis. Your words and those of the First Lady of Panama, strongly resonate for countries in Eastern Europe and central Asia.

Eight out of 12 countries in Eastern Europe and Central Asia, including the largest one, have been reporting a continuous increase in the number of new HIV infections and on an epidemic that continues to grow by about 10% per year.

Also of significant concern is the steady increase in the number of HIV-TB co-infections. The number of people living with HIV among newly diagnosed TB cases has doubled in the last five years; HIV-TB co-infection in the region, often means co-infection with resistant forms of TB.

Despite the acknowledged concentrated character of the epidemic, testing and access to prevention programs remains low among vulnerable groups of the population. Harm reduction programs for example, reach less than 10% of PWID in the region. Opioid maintenance therapy is now part of the national strategy in nine of the twelve countries of EECA but remains illegal in three.

Access to antiretroviral treatment also remains low, of less than 25% of those estimated to be in need, although these figures have been significantly increasing in several countries in the region in the last three years. The region has conducted strong and effective programs to prevent vertical transmission of HIV.

Stigma is high and many obstacles of societal, cultural, legislative and political nature remain. We still have much to do to ensure that the tremendous programmatic knowledge we have about how to respond to concentrated epidemics is more effectively translated into national strategies.

As a Special Envoy, I have conducted high level advocacy and dialogue to promote country-specific strategic priorities to fast-track the AIDS response. I focused on addressing the needs of key populations and on the issue of sustainable financing for the fight AIDS, TB, DR-TB and hepatitis in a region where funding from international sources has been diminishing or discontinued. More specifically, I also worked with local and international partners to ensure uninterrupted access to HIV and DR-TB treatment for people living in the conflict areas of Eastern Ukraine and for labor migrants in Central Asia.

It has been an honor to serve under Secretary General Ban Ki Moon whose commitment to the fight against HIV/AIDS and to the health of the most vulnerable I had learned and respected also throughout my years at the Global Fund. I welcome SG Guterres’s commitment to human rights and development.

I would like to particularly thank Michel for his support; thank the regional and country teams of UNAIDS, WHO, UNDP, UNODC, UNFPA and UNICEF for a truly excellent cooperation; thank the governments, civil society and community organizations in the region for a trustful relationship throughout these few years.

We need to maintain the international leverage and dialogue in the region.

I remain strongly positive, recognizing the progress that is being made, having faith in the wonderful people of the region and remaining confident that if we do what needs to be done, the fight against AIDS in the region will ultimately be won.

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The Shifting Diplomacy around Migration, HIV/AIDS and Tuberculosis in Central Asia

March 23, 2017, The Huffington Post 

Central Asia and the Russian Federation face a major intra-regional migration flow, home, as it is, to one of the largest labor migration corridors in the world, with hundreds of thousands of migrant workers moving from Central Asian countries to the Russian Federation and to Kazakhstan each year.[1] This migration flow of further concern given migrants’ increased vulnerability and poor access to HIV and TB prevention and care in host countries.

The Eastern Europe and Central Asia region is home to the fastest growing HIV epidemic in the world. Over the last five years, the number of new HIV diagnoses has more than doubled in Eastern Europe. In Russia alone, it is estimated that over a million people are living with HIV compared to around 250 000 a decade ago.[2] Nine Eastern European and Central Asian countries are also among WHO`s global list of Multidrug Resistant Tuberculosis (MDR-TB) high burden countries.[3]

In Kyrgyzstan, Tajikistan, Uzbekistan and also Armenia, substantial parts of the population are migrating to neighboring Kazakhstan and the Russian Federation for work purposes. Migration is clearly recognized as a risk factor for TB, MDR-TB[4] and HIV[5]. High mobility and seasonal migration patterns associated with poor living and working conditions, are contributing factors towards increasing migrants’ vulnerability and exposure to HIV and TB in the host country where they often experience significant barriers in accessing healthcare services.

For instance, over sixty percent of people who have been detected as HIV-positive in the last three years in Armenia, have, at one point, migrated to the Russian Federation for work. Non-governmental organizations in Kyrgyzstan and Tajikistan report evidence of a growing number of HIV infections among spouses of men who return from labor migration.

A recent report from the Central Tuberculosis Research Institute of the Russian Academy of Medical Sciences indicated that the proportion of TB and MDR-TB among migrants is 2.5 higher than in the general population.[6] Reduced access to health services and the fear of deportation if diagnosed with TB and HIV means that many diagnoses are being hidden or delayed.

Today, only a minority of HIV-positive migrants in the Russian Federation is accessing antiretroviral therapy (ART), while about 10 per cent of migrants are being tested for HIV and TB.[7] Despite pre-departure screening practices in the region for those requesting work authorization, many labor migrants are entering Kazakhstan and the Russian Federation without proper documentation in as much as there are visa-free travel agreements between countries. Scarce data on migrants’ health is an additional barrier to understanding how this group is affected by these diseases.

Notwithstanding, despite the barriers, there are also signs of cautious progress.

In the last few years, Kazakhstan has changed its policies, now ensuring access to full TB treatment for migrants irrespective of their legal status – and to MDR-TB treatment until the point that patients become sputum-negative. Although these clearly are progressive policies, many problems remain, including the conditions under which patients returning to their country of origin have to continue treatment to the end and the complexities of the patient referral system.

Under the auspices of the Kazakh Ministry of Health, with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria, bilateral agreements are being negotiated between Kazakhstan-Kyrgyzstan and Kazakhstan-Tajikistan on the access of migrant workers to TB care and treatment.

There is also progress in the Russian Federation around policies of both screening and requiring health insurance for migrants prior to entry on its territory. These policies allow for access to care of documented migrants at the site where they have registered for work. The downside to this measure however, is that many people are, however, emigrating for short period of times outside the registration system.

To reverse the rising HIV and MDR TB epidemics, the region will need to move forward on a number of fronts:

Firstly, there must be a halt to the deportation of migrants based on health status in the countries where it is still in practice. Currently, in too many instances in the region, a diagnosis of TB, MDR-TB or HIV means deportation, a practice that is widely known to be ineffective to public health, violate human rights, and may lead to drug resistant forms of infection.

Secondly, the region needs to ensure migrants’ have access to HIV services, including ART, and to full course TB/MDR-TB treatment in the host country. It will be vital that a funding mechanism be established to cover HIV and TB treatment costs for migrants who choose to stay in the host country to be treated.

Lastly, national and regional responses around infectious diseases like HIV and TB urgently need to be reviewed to include migrants as a vulnerable group.

It is no exaggeration to say that unless we see collective movement around the above fronts, all the ingredients of a brewing regional public health crisis will continue to bubble away.

—————————————

[1] IOM (2015) Mapping on Irregular Migration in Central Asia 2014, Astana, 2015.

[2] Unaids (2016) Prevention Gap Report.

[3] WHO (2016) Global Tuberculosis Report 2015.

[4] Dara M et al. (2012). Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. The European Respiratory Journal, 40(5):1081-90. Published online 2012 May 31. Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485571/

[5] Unaids (2014) The Gap Report.

[6]Demikhova O, Nechaeva O (2016) Access of Migrant to Services on Early Detection, Diagnosis, Prevention and Treatment of Tuberculosis and Tuberculosis Associated with HIV Infection, Moscow, (In Russian : Вопросы доступа мигрантов к мероприятиям по раннему выявлению, диагностике, профилактике и лечению туберкулеза и туберкулеза, сочетанного с ВИЧ-инфекцией в странах СНГ) Available at : http://mednet.ru/images/stories/files/CMT/migranty.pdf

[7] Demikhova O, Nechaeva O (2016) Access of Migrant to Services on Early Detection, Diagnosis, Prevention and Treatment of Tuberculosis and Tuberculosis Associated with HIV Infection, Moscow, (In Russian : Вопросы доступа мигрантов к мероприятиям по раннему выявлению, диагностике, профилактике и лечению туберкулеза и туберкулеза, сочетанного с ВИЧ-инфекцией в странах СНГ) Available at : http://mednet.ru/images/stories/files/CMT/migranty.pdf

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WOMEN’S HEALTH AND RIGHTS, MORE THAN EVER THREATENED

The commitments made by the governments to support access to treatment and care, defense of human rights, fight against inequality, discrimination, vulnerability and violence – and the values that underpin them – are always measured in the light of health and women’s rights.  We are all reminded of this in celebrating women today, on the occasion of International Women’s Day.

By placing women’s health and rights at the heart of the Sustainable Development goals adopted in September 2015, the international community recognizes their power for development. Despite the incredible progress made in recent years in global health, progress for women’s health remain insufficient.

– HIV / AIDS is the leading cause of death for women aged 15-44 worldwide and tuberculosis is among the top five causes of women death in this age bracket in low- and middle-income countries.

– Every week 7,500 women and girls aged 15-24 years, are infected with HIV. 60% of new HIV infections among 15-24 years old are contracted by girls and women. In HIV high burden countries, 80% of newly infected adolescents are girls.

– 35% of women worldwide have experienced intimate partner violence or non-partner sexual violence.

– 225 million women who do not wish to become pregnant, do not have access to modern contraception and family planning means. Every year, 74 million of unwanted pregnancies are counted in developing countries, which will result in 36 million of abortions and among them 21 million are unsafe generating about 13% of maternal deaths.

By reinstating the Global Gag Rule 101 on January 22, President Donald Trump directs the Secretary of State, the Administrator of USAID and the Secretary of Health and Human Services to take all necessary actions, to the extent allowable by law, to ensure that federal US public resources will not fund any organization or program supporting or participating in the management of coercive abortion or involuntary sterilization.

Consequently, any non-governmental US organization financed by federal funds, not only for family planning but also for global health, HIV / AIDS and maternal and child health may not provide nor promote services relevant to abortion or providing abortion as a method of family planning, nor inform nor advocate for such measures on both US and foreign soil. This prohibition applies to the entire activity of these organizations regardless of their source of funding. Should these organizations not comply with these prescriptions, they would lose all the resources from federal US funds, including those dedicated to the provision of condoms or modern contraceptives for women.

Those restrictions deny the major effects of sexual and reproductive health on women’s health, global health and development.

By increasing unwanted pregnancies, unsafe abortions, and maternal and child deaths, this decision endanger years of hard-won gains, not only from reproductive and maternal health, but also from the fight against HIV / AIDS and other sexually transmitted infections, as well as child health.

When a woman is able to choose the number of pregnancies, spacing between two births, she can better manage her resources and give her children better nutrition, better health and a better education. Giving children a better chance to live better is the right way to fight poverty.

Such restrictions alter the living forces of development. They destroy entire sections of global and community health services, expertise, know-how, and partnerships that are so difficult to build on.

Finally and even more severely, by limiting women’s rights, autonomy, ability to economically empower themselves and to support the development of their communities, they help to keep countries and populations in poverty.

The international community cannot ignore the consequences of these provisions and their impact on global health and development. It must mobilize any additional resources to continuously and sustainably provide all women and girls with the indispensable services that guarantee health, autonomy and rights.

 

Laurent VIGIER, former advisor of the French President, Jacques Chirac for International Summits and multilateral instruments – Chair of Friends of the Global Fund Europe Board

Heidemarie WIECZOREK-ZEUL, Former German Minister for Economic Cooperation and Development – Vice-Chair of Friends of the Global Fund Europe Board in charge of GERMANY

Charles GOERENS, former Minister of International Cooperation and Humanitarians Affairs, Member of the European Parliament – Vice-Chair of Friends of the Global Fund Europe Board in charge of The European Institutions – Luxembourg and Belgium

Stefano VELLA, Director of the Center for Global Health, Italian National Health Institute – Vice-Chair of Friends of the Global Fund Europe Board in charge of ITALY

Michèle BARZACH, former French Minister of Health – Member of Friends of the Global Fund Europe Board

Michel KAZATCHKINE, UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia  – Member of Friends of the Global Fund Europe Board

Andris PIEBALGS, Former European Commissioner for Development – Member of Friends of the Global Fund Europe Board

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Towards a new health diplomacy in eastern Ukraine

March 2017, The Lancet HIV

Conflicts and resulting humanitarian crises in countries with high burdens of infectious disease present political, strategic, and logistic public health challenges for agencies charged with implementing health programmes. One need look no further than the ongoing conflict in eastern Ukraine, to illustrate this.

Access to treatments for HIV and drug-resistant tuberculosis in the separatist Donetsk and Luhansk territories has been an issue of concern from the early days of the conflict. Even before the conflict, these regions had some of the highest incidences and prevalences of HIV and drug-resistant tuberculosis in Ukraine and Europe. Donetsk has an estimated 30 000 cases of HIV and Luhansk 5000—above 1% of the population in both territories. 18 000 patients are enrolled in care in the territories and 8200 patients are on antiretroviral therapy. 2200 cases are newly diagnosed each year, and an estimated 12 500 patients will be in need of treatment at the end of 2017 (on the basis of a CD4 count eligibility threshold of 500 cells per μL).

As of March 1, 2016, there were 650 patients with drug-resistant tuberculosis on treatment in Donetsk and Luhansk. During the period of May 2016 to December 2017, an additional 900 patients with drug-resistant tuberculosis are expected to require treatment in the civil sector and the prison sector. The situation is of particular concern in the penitentiary sector because international programmes focusing on drug-resistant tuberculosis, including that of Médecins sans Frontières, were discontinued by the local authorities at the end of 2015. Medical needs associated with HIV and tuberculosis also include laboratory supplies for testing (including GeneXpert), CD4 cell counts, and plasma viral load measurement, as well as ensuring laboratory quality control.

Finances are needed to sustain the work of non-governmental organisations (NGOs) that support patients in care and prevention programmes, including the distribution of clean injecting materials for people who inject drugs—opioid substitution programmes were discontinued in both Donetsk and Luhansk in 2015. Before the conflict, most antiretroviral drugs were funded by the Ukrainian Ministry of Health. Medicines for drug-resistant tuberculosis were funded by the Global Fund To Fight AIDS, Tuberculosis, and Malaria and channelled to Donetsk and Luhansk through a Ukrainian NGO. However, the funding for medicines was discontinued in both the Donetsk and Luhansk territories by the Kiev authorities at the end of 2014, when these territories (and self-proclaimed Donetsk and Luhansk Peoples’ Republics) were declared by the Ukrainian Government as non-government-controlled areas (NGCAs).

In June 2015, I expressed concern about the pending risk of an abrupt interruption in the availability of antiretroviral drugs for thousands of patients with HIV in the Donbass (the region of which Donetsk and Luhansk are part). The clinics in Donetsk and Luhansk continued to treat patients until July 2015 when the interruption to supply became an urgent public health threat. What followed were intense health diplomacy efforts to alert and then to involve the de facto authorities in the NGCAs, the Ukrainian Government, the European Commission, bilateral donors, the UN and the Global Fund. The primary aim was to frame the critical situation to all stakeholders as a humanitarian emergency that required a special set of responses that were geared to ensuring stakeholder cooperation with the twin goals of securing funding for the essential medicines and providing access on the ground to the affected peoples in the conflict region.

Meetings with self-proclaimed officials in Luhansk in January 2016 and Donetsk in March 2016 resulted in roadmaps to seek temporary solutions to the risks of interruptions to supplies of drugs to treat HIV and drug-resistant tuberculosis until the end of 2017. Health diplomacy facilitated the search for possible funding sources to finance emergency support to the NGCAs, which ultimately brought together the Global Fund, UNICEF, WHO, UNAIDS, the Ukrainian Government, and non-governmental partners to set up the mechanism that enabled the drug supply needs to be met and soon came in the form of an emergency grant of US$3·6 million from the Global Fund to UNICEF, covering the supply needs of antiretroviral medicines and laboratory reagents in both territories for 1 year. The Global Fund is considering an extension to this grant. UNICEF successfully implemented a public health approach in which most treatment naive patients would start ART on an optimised single pill formulation of tenofovir disoproxil fumarate, emtricitabine (or lamivudine), and efavirenz and 60% of patients already on first-line therapy would switch to that regimen, resulting in significant financial savings.

Funding for drug-resistant tuberculosis medicines procurement was consolidated in the Global Fund grant to the Ukrainian NGO recipient until the end of 2017. All in all, a solution was found for over 10 000 HIV patients on antiretroviral treatment in the NGCAs and about 500 cases per year of people living with drug-resistant tuberculosis.

Of equal importance to funding guarantees, the Donetsk and Luhansk de facto authorities agreed on key logistic issues, including facilitating the delivery of antiretroviral drugs to the territories by UNICEF and that drugs to treat drug-resistance tuberculosis were still to be provided under the Global Fund grant and delivered safely and on expected schedule to Luhansk. The medical teams and authorities were also made accountable for delivering care and treatment and provide the needed epidemiological and treatment monitoring and evaluation data to WHO, according to international standards.

This diplomatic intervention was a success in terms of permitting the delivery of essential medicines; however, that is only a short-term solution while uncertainties around drug supply remain. The most realistic solution for the mid-term, beyond 2017, is to have the issue of the funding of HIV and drug-resistant tuberculosis treatments addressed within the frame of the Minsk negotiation process on the future status of the Donetsk and Luhansk separatist territories within Ukraine. Since mid-2016, discussions have been underway with the support of the Chair of the Humanitarian Working Group for the Minsk process, with the governments of France, Germany, the Russian Federation, and Ukraine and with the European Union, to attempt to place the issue of the funding of expensive tuberculosis and HIV medicines on the agenda of the negotiations.

The evolving geopolitics in Ukraine, Europe, the Russian Federation, and the USA brings fragility to the Minsk process. If no solution is found in the coming months, the region may again be at risk of treatment interruptions for HIV and drug-resistant tuberculosis that would lead to a regional public health crisis.

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