To tackle the problem of increasing TB spread in these high burden countries the states are reliant on financial support from abroad. In the last decade these countries have received almost 50 million euros for TB control. Germany is among those that help: On the orders of the Federal German Government, the KfW Development Bank in Frankfurt is supporting national programmes for TB control in four central Asian countries (Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan) and in the Southern Caucasus (Armenia, Georgia and Azerbaijan).
Dr Peter Reff, a Senior Medical Expert in the Health and Education Division Asia at the KfW Development Bank, explained that, to obtain financial support, it is important for developmental cooperation that ‘…the health authorities in the countries that apply for financial aid show the political will to implement the DOTS (directly observed therapy, short-course) strategy recommended by the WHO.’ This is a system introduced worldwide for the diagnosis and therapy of TB. DOTS comprises standardised diagnostics and a therapy scheme standardised as to length and content. The occurrence of new challenges in the form of multi-resistant pathogens and the increasing number of concomitant infections with HIV meant that the DOTS strategy was extended by additional points in 2006. The method was initially not implemented at all, or only to a slight extent by many Eastern European countries; however, it has now become established, Dr Reff said.
Once a contract is entered into with the KFW Development Bank the national projects are allocated precise means and objectives whose use and achievement can be monitored by the KfW Development Bank as a financing institution. Responsibility for the implementation of the projects is taken on by national institutions on site; however, other organisations such as the WHO, Médecins Sans Frontières and the International Red Cross are involved in the technical implementation.
Realistic programme planning is important. Initially two essential financing objects are the development of a laboratory network and the availability of medication. The KfW Development Bank, in cooperation with the Red Cross, has put particular emphasis on the fact that TB control should also be implemented in prisons, starting in Uzbekistan and Kyrgyzstan, then all other countries in Central Asia and the Southern Caucasus. The risk of infection in prison is 50 times higher than in other social environments, moreover, the occurrence of multi-resistant pathogens is particularly high there. ‘Prisons were considered the breeding ground and engine behind the TB epidemic,’ he pointed out. ‘The occurrence of multi-resistance due to insufficient and wrong TB treatment is a big problem in general. Diagnosis as well as therapy has therefore become much more complex and far more expensive. With a normal TB infection the cost of medicines is around US$10 annually, but in the case of multi-resistance it is more than ten times that.’ The development of national reference laboratories, which ensure fast and efficient diagnosis of this infectious disease, is therefore often part of the programmes. These countries profit from Western European expertise here. In this, the KfW Development Bank can, in some cases, initiate the first contact between different institutions. ‘In some cases,’ said Dr Reff, ‘there are no efficient reference laboratories in the developing countries, which could ensure national quality control. Therefore we have initiated an exchange programme between laboratories in Uzbekistan, Tajikistan and Azerbaijan and the super-national reference laboratories in Borstel, near Hamburg, and Gautling, near Munich, both of which have the gold standard for TB diagnosis awarded by the WHO. The medical staff visits each other and have a very lively exchange of information.’
As TB is a cross-border problem it also requires regional communication, he emphasises. ‘Transparency and openness in dealing with TB are important, seeing that it is one of the largest health problems in these regions since the beginning of the 1990s. We are very interested in supporting the governments, in developing networks and in facilitating a mutual exchange. This has already been achieved with our Caucasus initiative and in Central Asia. There are regular regional conferences where experts exchange experiences and TB data, or where staff training may also be carried out in some cases. This is particularly remarkable considering that these countries are, in some cases, officially still at war with one another.’