Thursday, March 24, 2011

FT: Romania: ‘The future looks really dark’

By Andrew Jack

Published: March 23 2011

Marioara Micu, the TB manager for Ages district, holds a morning meeting with local officials, visits a sanatorium until mid-afternoon, and then stops off in the regional capital’s hospital to clock in for night duty.

Like dozens of her colleagues in the Romanian government’s National TB Programme, including its director, she remains a full-time clinician, seeing patients and trying to make ends meet on her modest salary.

Yet she also volunteers in a second job, helping manage prevention, diagnosis and treatment of one of the country’s most serious infectious diseases.

“Sometimes, the TB managers look tired and burnt out, but we don’t criticise them,” says Silvia Asandi, head of Romanian Angel Appeal Foundation, a non-governmental organisation involved in tackling the disease. “We understand. They donate their time.”

Lack of money is one frequently cited difficulty of dealing with tuberculosis in Romania.

Accelerated by the 2008 crisis, the result has been: a squeeze on doctors’ and nurses’ salaries as living costs have risen; restrictions on drugs and diagnostics; and scant funding for training or programmes of incentives for patients to take their medicine.

Many doctors have sought ways to supplement their income in the private sector, or emigrated, further weakening medical infrastructure in a country that already has one of the lowest ratios of doctors to citizens in the European Union.

Others have faced important infection risks while treating TB patients.

“Money is very important, but more important are the people,” says Elmira Ibraim, head of the national TB programme. In her office in the Marius Nasta Institute of Pneumology in Bucharest, in between patient consultations, she points to figures showing impressive overall progress.

The disease rose steadily in Romania from the mid 1980s, accelerating after the revolution in 1989 to reach a peak of 31,000 new cases in 2003, reflecting increased migration, unemployment and social problems at a time of transition.

It has since steadily declined, reaching a little over 19,000 last year.

But that still remains the highest absolute number of cases anywhere in the EU, and the largest in the broader European region after Russia and Ukraine.

The overall trend conceals important nuances.

Dr Ibraim shows a map indicating a close correlation between TB and social problems, with the greatest concentrations on the more rural, impoverished eastern and southern borders.

Furthermore, she estimates that more than 700 patients a year are contracting multiple-drug resistant MDR-TB, which is far more costly and complex to treat, requiring drugs over two years. A 10th of these have extremely resistant (XDR) strains, which is still more difficult to tackle.

Samples from fewer than half of patients who do not respond to first line drugs are tested for resistance, suggesting that many cases are not being counted.

The money from international donors through the Global Fund to Fight Aids, Tuberculosis and Malaria will run out next year, with the last cohort of MDR patients it is supporting set to be recruited by June. There is scant sign of alternative sources of funds.

“TB is a huge public health issue, but I just don’t feel the decision-makers understand or are taking any action,” says Dana Farcasanu, head of the Centre for Health Policies and Services in Bucharest.

“We are talking about free movement of [contagious] people. This is a security issue, but I just don’t see any concern at EU level.”

She also criticises decentralisation introduced into the health system in 2007, which may have theoretical advantages but has further fragmented treatment and undermined community nurses and Roma mediators who were reaching the most affected groups.

Drug procurement has also suffered, with inexperienced local staff handling smaller quantities of TB drugs causing “stock outs” that risk causing further drug resistance in patients.

The government has promised to recentralise purchases, but is yet to act.

At Dr Ibraim’s institute, and another in the north of the country, MDR patients have access to good care. At other units, including the Valea Iasului sanatorium with more than 100 beds for first-line treatment, the conditions appear good.

Yet at a time of resource constraints, there will be a growing debate over whether the money used on such specialist centres should instead be reallocated to a “community-based” model, with those with TB discharged rapidly and treated as outpatients.

“The future is really dark,” says Ms Asandi.

“The Global Fund was a real success, but we don’t see any other source of funding. We have days when we are really depressed. We have a problem, we have the solution, but someone needs to give us the money.”

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