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Improving the health of the population in Romania by increasing TB control

Project financed by the Norwegian Grants 2009 - 2014, within the RO 19 - Public Health Initiative.

Interview with Mr. Răzvan Vulcănescu, Undersecretary of State within the Ministry of Health

This year, the Romanian Government passed the National Tuberculosis Control Strategy, a commendable decision that was received with optimism by all stakeholders. The strategy’s objectives, to be reached by 2020, aim mainly to ensure universal access to rapid diagnostic methods, to diagnose at least 85% of all the estimated cases of sensitive and multidrug-resistant tuberculosis (MDR-TB), to successfully treat at least 90% of the new cases and at least 85% of re-treatments, to successfully treat 75% of the multidrug-resistant tuberculosis cases, to decrease the disease incidence and to improve the healthcare system capacity to control tuberculosis.
The Ministry of Health is currently the Operator of the “Public Health Initiatives” programme, through which the Norway Grants 2009 – 2014 finance the project Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control. The project’s major components concern the increase of the rapid diagnostic capacity for multidrug-resistant tuberculosis, the provision of the correct, complete and quality treatment for MDR-TB patients, measures for maintaining treatment compliance and, last but not least, the development of a functional network of TB laboratories and facilities countrywide, with modern equipment and trained staff, in order to enhance the capacity for tuberculosis control.
Mr. Răzvan Vulcănescu, Undersecretary of State within the Ministry of Health, has given us an interview in which he spoke about the role of this project in the context of the National Tuberculosis Control Strategy and the way in which the institution he represents will ensure the sustainability of the implemented interventions.

So, mister Undersecretary, what is the role of the project Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control in the implementation of the National TB Control Strategy 2015-2020?

Thank you for addressing this subject in this interview, one that we also consider very actual and very important, and we appreciate the collaboration we have with the Marius Nasta Institute and its partners in this project. Before I answer your question, I would like to make a little introduction, because just like this project comes to support the National Tuberculosis Control Strategy, the National Tuberculosis Control Strategy is part of our Health Strategy called Health for Prosperity, which we passed last year, by Government Decision, an initiative that has been built over the course of several years. I started this initiative, as coordinator of the working group at that time (2012), which aimed at bringing together the entire medical community responsible in Romania in order to build this health strategy to which we could all contribute and make sure it would help us solve the major health problems we are facing. I was very glad that the final outcome was this strategy, which was passed at the end of 2014 by the Government of Romania. It is very important to remember that it is part of the Partnership Agreement with the European Union for the programme period 2014 – 2020 and that it seeks to ensure the necessary funding for a complementary financing to what is provided by the Government, and the funding necessary for us to be able to control the major public health problems that we are facing. Obviously, after the National Health Strategy was passed, the National Tuberculosis Control Strategy followed and it was precisely in order to support this strategy that we were very happy with the existence of the Norway Grants that we tried to use in order to cover those very gaps that were not covered by our Government funds, or as a supplement to the allocated money. So, there are elements of complementarity, elements of similarity, but, of course, our main purpose is to seek and support, in all our initiatives, the control of tuberculosis in Romania.

What are the plans of the Ministry of Health in order to ensure the sustainability of the interventions implemented in Romania through the two projects which, at this moment, come to support the Strategy? (I’m talking about the two major national projects: Project RO 19.01, financed by the Norway Grants, and ROM-T-RAA, financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Under these two projects, Romania receives support for ensuring the rapid and qualitative diagnostic, the correct, continuous and complete treatment for the patients with MDR/XDRTB, the start of the reform in relation to the outpatient care of TB patients through social support services, in order to maintain compliance, the early detection of TB cases among vulnerable populations – the homeless and the injecting drugs users.

What you have mentioned are in fact the objectives that we would like to reach by implementing these projects. In fact through the two projects, Romania receives support for ensuring rapid and qualitative diagnostic and continuous and complete treatment for TB and MDR-TB cases, practically the beginning of the reform of outpatient care for TB patients, through social support services, in order to maintain compliance and actively detect TB cases among those vulnerable populations (here we can think of the homeless or people of a certain ethnic origin, or users of injecting drugs). The interventions financed from the Norway Grants and from other international funds as well, will be taken over and will be ensured the amounts and financing resources in accordance with the National Tuberculosis Control Strategy.
I would also like to present a part of the concrete results that we have already obtained through the implementation of the two projects. Specifically, speaking about the activities set out in each project, we can say that, halfway through, we already have palpable results that motivate us to take these projects further as they have been carried out so far. First of all, with regards to the strengthening of the capacity to control the TB epidemics, I can tell you that more than one third of the pulmonology medical staff has been trained on TB control since the beginning of the project. The total number is 600 professionals. Furthermore, if we consider the activity related to the strengthening of the rapid diagnostic capacity for TB and MDR TB cases and the increase of the detection rate when using rapid diagnostic method that are standardised in terms of quality, the methods that we used until now will be doubled by much more efficient methods and, in the following two months, at most, along with the existent tests, we will also have available the GeneXpert tests that can give the diagnostic for TB and for Rifampicin resistance. This test can give a result in two hours. Also, since April 2015, over 6600 persons have been tested, of which 1643 were detected with tuberculosis and 171 with multidrug-resistant tuberculosis. So, we already see real results and we begin to identify and treat patients from the risk categories that we have on record. Also, starting this month –September 2015 – we will also have available under the project the vehicles that will carry the samples from the peripheral laboratories to the regional and national reference laboratories, in order to ensure a correct and rapid diagnostic.
We can go further and look at the activity related to the provision of continuous, complete and quality treatment for 1000 patients with TB and MDR TB, and I can confirm to you that so far, over 200 patients have been enrolled in the treatment cohort. These patients receive complete, continuous and quality treatment, in accordance with the identified resistances and, moreover, starting this month, the patients enrolled in this project will also receive a drug that has been approved by the World Health Organisation (editor’s note WHO) for the treatment of MDR TB. As for the provision of directly observed treatment and incentives for TB patients treated in outpatient care facilities, in order to increase treatment compliance, so far, around 440 TB patients with increased default risk treated in these facilities have received support in order to maintain treatment compliance. This means that over 80 % of them have continued to be compliant for a period of 4 months. This initiative is very important for us, because before we had to monitor them and each time we would lose track of them they would return in a more complicate stage of their condition, which also implied higher costs. So, it is very important that once the procedure is initiated for each identified patient, the procedure is continuous and focused in terms of the efforts that we all make in order to motivate them to stay with the treatment until there is a medical confirmation that the risk period has been surpassed entirely or even that the patient is completely cured.
Basically, all the activities are implemented according to the schedule and, at this point, approximately 45 % of the results initially planned for this time interval have already been achieved. This is an effort that has been assumed by both the Ministry of Health and the project management team within the ministry, which coordinates and monitors the entire activity of our partners in the system. It is an effort that we have assumed precisely in order to properly carry out the projects.

You talked earlier about the provision of funds for the sustainability of the activities. Have the sources of these funds been identified so far?

Yes, there are multiple sources and, of course, as we are nearing the end of the year, we must consider about the budget planning for next year, for 2016. Soon, all the aspects related to the budget law for the following period will begin to be discussed, and we will have much to say about how things stand at this point, given the experience we have gained with the implementation of these projects. The main idea and the idea that we are trying to focus on is, as I was telling you earlier, related to funding complementarity, so that we can have continuity in the provision of the funds. Also, for what the Government is unable to provide during a certain period of time, we have to make sure that there are other financing sources available that we can use for that period. However, there is support and openness from the Ministry of Finance as well, and it is very important for us that we are now able to show clear results. Because the Ministry of Finance is interested as well to see that these measures that we have undertaken lead to concrete results that justify the need to continue to fund these activities from the national budget.

In order to ensure the sustainability of the interventions financed from international funds, how will the Ministry of Health deal with the current constraints of the National Tuberculosis Control Programme, which are shown in the latest WHO / ECDC (European Centre for Disease Prevention and Control) assessment report? Among these, we mention only a few:
a.The updating of the C2 list of drugs with all the tuberculosis drugs necessary for the complete and correct treatment of MDR and XDR TB patients, in accordance with the WHO recommendation
b.The reorganisation of the laboratories in the NTPSCP network
c.The review of the financial payment mechanism for the NTPSCP programme (e.g. the payment per services instead of per invoices issued)
d.The review of the procurement procedure for drugs for TB patients

I appreciate your question in the context of the meeting that will take place next week, in Vilnius. It is the Annual WHO Congress, where I will represent Romania (I have also represented Romania on previous occasions). The World Health Organisation is very preoccupied with the eradication of tuberculosis worldwide, and is in particular concerned about Romania, but not only. Because there are states right know where we can speak of a relapse. And this happens precisely in the current context of the migration. Probably this will be a topic on the agenda of the talks next week – what happens in the context of the migration and in the context of the allocation of these categories of population to the European states, with all the implications that their health might have on the health of the population where they are to be relocated. So, tuberculosis is not only a health problem, it also has socioeconomic implications. As such, in order to improve and control tuberculosis in Romania, we need the involvement of each and every institution and organisation, as well as of the partners who have a say in what tuberculosis represents in Romania. I would like to say that, in accordance with the National Tuberculosis Control Strategy, the Ministry of Health and the National Tuberculosis Prevention, Surveillance and Control Programme will also benefit, under internationally funded projects, from technical assistance from the WHO, in addition to the European Financial Mechanism, the Norway Grants and the Global Fund. I will personally discuss these key aspects during the meetings next week, and they could become the topic of further talks with you, where I could present the latest elements resulted from the meeting that I will attend.

Thank you for giving us this interview.

Thank you for our collaboration in working to keep under control a disease that is challenging for us and that we are trying to eradicate.