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Techies, bankers treading softly
Negotiations between Russia and the World Bank over a $150 million loan to fight TB and HIV/AIDS are back on track, and the loan is expected to go through sometime next spring, according to bank officials. The loan talks unexpectedly collapsed last May, apparently under the weight of opposition from the country’s pharmaceutical industry. Even though the Russian TB control program was suffering at the time from a severe shortage of first-line TB drugs, the Russian drug industry objected, fearing its products wouldn’t qualify under the competitive rules for procurement built into the loan. Having decided it stood to be undermined by those rules, Russian drug makers reportedly convinced the health ministry to pull out of the loan talks.
According to Wieslaw Jakubowiak, a technical staff member for the World Health Organization in Moscow, the new agreement will let the Russian government use its own money — though not the bank’s — to buy drugs from whomever it likes, including Russian manufacturers. The Russian drug makers, in turn, have agreed to work with international experts to bring their products up to acceptable standards.
More compromises have been struck between the Russian TB control establishment and the World Health Organization (WHO), with both sides reportedly softening their respective positions.
"We have an ideal scenario, an as-is scenario," says Armin Fidler, health sector manager for the World Bank in Europe and Central Asia. "We may wish that the Russians would throw out a hundred years of medical tradition, but obviously it will take a while for all that to change. Moving between where we are now and where we want to be will take time — and progress may not always proceed in a straight line."
That has meant that WHO hardliners have had to soften their positions considerably, a tack some insiders say has left some TB experts at the organization fuming. "There’s a certain amount of dogma in public health and at WHO," says Fidler. "There’s been the same sort of debate over vertical vs. horizontal programs, for example. But we can’t expect the Russians to simply throw [away] 100 years of tradition."
Trying to allay suspicions
Fidler adds that the bank, for its part, needed to work harder at building trust and allaying suspicions among the Russians. "There was the widespread perception on the Russian side that we were a commercial-style bank, not a development agency, and that we were keen to make this loan," he says. "We reassured the Russians that we know it’s not the 1980s anymore and they’re no longer desperate for cash. We shift the focus away from the TB loan to other projects we were working on at the time. Even so, we never took the loan off the table."
In the United States, some TB experts say privately that they worry the Russians simply will take the bank’s money and do with it as they please. For the record, TB experts at WHO say they’re happy with the new agreement.
"DOTS has always been a flexible strategy, able to be adapted to specific country conditions, and both sides are very pleased with what’s happened," says Marcos Espinal, MD, coordinator of WHO’s DOTS-Plus program, and focal point for TB activity in the Americas and the Russian Federation. "Russia is a huge country, and it’s got special characteristics. We’re working closely with Russian authorities, and we understand that we need to be flexible."
That means Russia will make some changes in accordance with WHO treatment strategies, but will still be allowed to retain some elements of its own costly and inefficient system for treating TB. "Before, the system was weighted heavily toward hospitalization," says Espinal. "They may still need to hospitalize some patients. For example, in some faraway places, outpatient treatment may not prove not to feasible."
Likewise, the Russians will continue their practice of doing cultures, considered too costly for developing-world settings — but have agreed to implement smear microscopy as well. "The Russians were worried that implementing DOTS would mean replacing cultures with smear microscopy. We’re not against cultures. If the Russians have the resources to do both, they should do both."
Some disagreements persist
Some points of disagreement between the technical experts and the Russians are yet to be ironed out. According to Jakubowiak, "we still need to reach a consensus on the issues of active case finding and the role of fluoroscopy," both practices considered by WHO to be costly and inefficient. "We’re working to help them become more cost-conscious," adds Jakubowiak. "But we understand that will take time."
For years, some in the old-school Russian TB establishment have resisted the widespread implementation of DOTS, calling it (in one American TB expert’s words) "soup-kitchen medicine" that is better suited to homeless Americans or dusty third-world countries, than Russia. Not surprisingly, part of the new approach has been to avoid using hot-button words such as DOTS.
"Instead, we’re simply calling it the WHO strategy,’" says Jakubowiak. The same approach is bearing fruit in other parts of the region as well. Ukraine, for example, recently signed onto a TB loan from the bank, after resolving to call DOTS-like changes in its TB control program "The National TB Control Strategy Adapted to World Standards."
Where the money goes
Of the $150 million loan, $100 million will be spent on TB control, with the remaining $50 million going to control HIV and AIDS. The case rate of TB in the country ranges from 85 per 100,000 to as high as 300 per 100,00 in some areas; and more than 100,000 prisoners have TB, of whom as many as 30% have drug-resistant forms of the disease. Last year, for the first time in many years, case totals showed no increase. Experts at both the bank and WHO both concede it’s still too soon to call the loan agreement a sure thing. "After all, this is Russia," says Fidler. "Obviously, we’re not completely out of the water."