Georgia is committing both financial and human resources to an overhaul of its national TB program to address the growing problem of MDR-TB in the country, signalling its willingness to pay -- and to change -- as it develops its TB concept note for the Global Fund.
Inconsistent reforms of the health system over the last two decades have contributed to the mounting toll that multi-drug resistant TB is taking on the country, which has placed Georgia 27th on the list of countries worldwide in terms of disease burden, with an incidence of 88 per 100,000 according to 2011 WHO figures.
The privatization of health facilities has, with hindsight, been seen as one of the major inhibitors of success in TB management. Because primary health facilities were not always equipped with the right equipment, or staff, to address the problems posed by tuberculosis among the general population, treatment adherence plummetted, driving the current problem.
Active coordination at the ministry level with Georgia's international partners including the Global Fund and the US Agency for International Development (USAID) has not translated to an integrated or holistic approach to TB at the community level, Aidspan understands. Considerable investment in modern diagnostic and treatment laboratory equipment has not been matched with a comparable investment in treatment; while 63% of MDR-TB cases are thought to have been identified, some 30% of those patients have failed to access treatment.
According to the national strategic plan, " once MDR-TB is detected, Georgia has succeeded in providing access to appropriate treatment, but the country has not yet achieved treatment success goals. Over one third of the MDR-TB patients who start treatment are later lost to follow up, and can also serve as sources of infection for others."
In the post-Soviet era, civil society, too, has been slow to engage with TB, which despite its wide presence, remains a disease that carries with it considerable stigma.
A commitment to overcoming these barriers is likely be the focus of the next NSP (2016-2018). Government has also committed to increasing state funding for the TB response, with an eye towards the gradual drawing-down of international support for TB programming, currently assessed at some 54% of the NTP budget.
One innovative approach that has earned modest success is underwritten partially by Global Fund grants. To encourage treatment adherence and overcome the sizable default rate, Georgia is providing a cash incentive for patients, to pay for the transport to and from medical facilities in order to be seen by health professionals. From 2015, this program is likely to see a commitment from the Georgian government to assume that financial outlay.
Country dialogue for Georgia's TB concept note is currently underway. It is anticipated that existing programs funded by the Global Fund -- medicines, including second-generation MDR/XDR TB drugs, diagnostics and lab equipment -- will be maintained, with some funding set aside to support community system strengthening to improve adherence and bolster civil society's ability to participate in the TB response.
“Georgia is developing its concept note for TB under the new funding model (NFM)," Dr Tamar Gabunia, the chief of party of the USAID TB program in Georgia and deputy chair of the country coordinating mechanism (CCM), told Aidspan. "The joint program review mission will be conducted in November 2014 by WHO, GDF and GLC experts to identify strengths and weaknesses of the national TB response. This review along with the financial gaps analysis will inform the new TB strategy and the investment proposals for domestic and donor funding for the next 3-5 years.”
Also likely to receive some financial support through the Global Fund allocation under the NFM are programs specifically targeting key populations. Co-morbidity of TB and HIV is estimated at 2% of all HIV-positive Georgians, and a TB component has since early 2014 been incorporated in the harm services provided by the Global Fund-supported Georgian Harm Reduction Network (GHRN).
People who inject drugs who are at high risk of TB are screened during GHRN outreach work, and then referred to TB centers for diagnostics, support and counseling.
Georgia is also having success with addressing the TB problem in its prisons. Since 2012, the number of active TB cases has declined to 47 from 533, and the number of cases of MDR-TB from 68 to 8. This can be attributed to a series of reforms to the health services being offered in the country's prisons, ensuring that "pretrial prisoners receive the same standard of TB services at a TB center as convicted inmates do," according to the Ministry of Corrections.
Also part of these reforms was the establishment of opioid substitution therapy and drug-rehabilitation services for prisoners, as well as HIV, TB and Hepatitis C prevention interventions.