Resistance to Implementing Policy Change: The Case of Ukraine /Resistance a la Mise En Oeuvre Du Changement Politique: Cas De l'Ukraine /Resistencia a Aplicar Los Cambios De Politica: El Caso De Ucrania

Introduction From 1990, the tuberculosis (TB) incidence rate in eastern Europe rose to reach a peak in 2001. (1) Although the rates have began to decline in many of these countries, they are still increasing in Belarus, the Russian Federation, the Ukraine and the central Asian republics of Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. (1,2) Eastern Europe, and in particular the Russian Federation and the Ukraine, also face increasing multidrug-resistant tuberculosis (MDR-TB). Of the 17 283 global MDR-TB cases reported in 2004, over 60% (10 595) were from the European region--especially from eastern Europe and the Baltic states of Estonia, Latvia and Lithuania. Treatment success levels for DOTS are substantially lower in eastern Europe than other regions of the world (except Africa), while DOTS coverage and smear-positive case detection rate are the lowest globally. (3) These problems are key obstacles to meeting Millennium Development Goals for TB in Europe. (2,3) Following the end of the Soviet Union in 1991, health systems in post-Soviet countries experienced substantial reductions in financing, decline in population coverage and huge increases in out-of-pocket payments. (3) Along with epidemics of sexually transmitted illness (STI) and injecting drug users (IDUs), (4,5) eastern Europe now has the world's fastest rate of growth of HIV incidence. (6) This paper explores the evolving epidemiology of TB, MDR-TB and HIV in the Ukraine as well as the policy and health systems' responses to these. The paper identifies shortcomings of these responses and, by drawing on experiences and evidence from neighbouring countries with similar TB control systems, it examines possible reasons for these shortcomings. It concludes by identifying options to strengthen health system responses to improve TB control. A cause for concern In the Ukraine, the second-largest country in eastern Europe with a 2005 population of 47.1 million, the incidence of active TB rose from 41.7 per 100 000 population in 1995 to 84.1 per 100 000 in 2005 (Fig. 1). In the same period, the prevalence of active TB increased from 193.1 per 100 000 population in 1995 to 219.1 per 100 000 in 2005 (Fig. 2). Meanwhile, the mortality rate from TB has almost doubled, increasing from 14.3 per 100 000 population in 1995 to 25.3 in 2005 (Fig. 3). But the TB burden is not evenly distributed. The incidence rate in penitentiary institutions is 3 to 4.5 times higher than the civilian sector. South-eastern Ukraine, which has a large number of penitentiary institutions, has incidence rates (e.g. Kherson region, 174 per 100 000; Mykolayev region, 111.1 per 100 000) that are 1.5 to 3 times higher than those in the capital city of Kiev (46.8 per 100 000; Fig. 1). (7) In 2005, the Ukraine reported a case detection rate of 86% for new and relapsed cases of TB and DOTS coverage rate of 29%, one of the lowest rates in Europe. The latter is of particular concern, as the Ukraine has one of the highest MDR-TB levels (10% of new and 29% of previously treated cases) in Europe. (8) In the WHO 2006 Report on Global Tuberculosis Control, the Ukraine was the only eastern European country for which no trend data was available for the notification and treatment success rates, collaborative TB-HIV activities and MDR-TB levels for the whole country. (1) TB and HIV As with TB, the incidence and prevalence of HIV has also risen. In 2006, there were 16 078 new registered cases of HIV, almost a tenfold increase from the number of registered cases in 1995 (Fig. 4). By 2005, Ukrainian authorities had reported a cumulative total of 88 626 HIV cases, but the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates put this figure nearer to 410 000, with an estimated incidence rate of 1.4% in adults aged 15 to 49 years. (9) The Ukraine is now the most HIV-affected country in Europe and has the second-highest number of HIV-positive people after the Russian Federation. …