From 12 until 16 August 2012, Paul Sommerfeld from TB Alert UK, Fanny Voitzwinkler from Global Health Advocates France and Cristina Enache from Romanian Angel Appeal met with TB advocates in Chisinau and Balti, Moldova. Our visit was facilitated by PAS: the Centre for Health Policies and Studies (NGO Principal Recipient of the Global Fund for TB and HIV) and Speranta Terrei (a community-based organisation based in Balti working with TB patients).

The main objectives of the TBEC visit were to inform local advocates about the TB Europe Coalition, EU advocacy, the Berlin Declaration and the M/XDR-TB Action Plan, to explore how TBEC might assist with the advocacy concerns of Moldovan NGOs and draw Moldovan TB advocates into TBEC.

13 August: preliminary meetings – Chisinau

During the first day of the visit, the TBEC met with the Centre for Health Policies and Studies (PAS) Director Viorel Soltan (former Deputy Minister of Health, former GFATM board member for the European region and current Chair of the Global Fund Finance and Operational Performance Committee) and his staff to get an understanding of the local dynamics when it comes to TB care and control, the impact of the GF cancellation of Round 11 and the current needs for improved TB control. Through the current national health reforms, PAS insists on TB care to become ambulatory rather than hospital-based. The Ministry of Health is open to it and is currently piloting a project (opened 10 community centres in 2011) in 4 regions. Valeriu Crudu (TB programme coordinator) and Irina Zatusevski (Communications officer) talked to us about the Community Health Centres project: These centres allow for the involvement of local authorities in TB care. One of the main problem is that TB doctors are old (average age: 55 years old) and have kept the old USSR mentality, which is hard to change. Mentality of patients also need to be changed, most of them think that 2 months of treatment is enough to be cured. The two biggest problems in Moldova are: late detection and interruption of treatment.  These community centres are staffed with a manager, 2 duty supporters (nurses or medical assistants) and a psychologist. They are paid very little (8$/month/patient) but this is usually not their main income. One of the main features of these centres is social support of patient (sanitary education, psychological counselling, DOT support). The centres are also equipped with a car, so staff can visit patients who don’t have the means to come to the centres. It is too early however to determine whether this project is successful. They haven’t seen any neighbouring country implement similar projects. It would be interesting for them to learn more about other examples and share best practices. One patient group exists in Balti. Otherwise, it is very difficult to convince former TB patients to be part of such support groups. Most of the time, they do not want to be remembered about the time they had TB.

We then went on to meet Lilan Severin, Director of Act for Involvement (AFI), sub-recipient of the GFATM, which works directly with patients and community specifically in the penitentiary system and also in Transnistria. AFI started DOT activity in prisons in 1999. They are now working in the 18 prisons of the country. CSOs are good partners for the penitentiary system as they are more skilled in dealing with TB/HIV early diagnosis, treatment adherence and follow up. AFI even managed to implement a needle-exchange programme in Transnistrian prisons. AFI is not involved in political advocacy directed at the government but has recently started roundtables with CSOs to discuss the financial problems for TB care in Moldova.

Finally we met with the Health Officer of the EU Delegation in Moldova, who pointed out that the Moldovan Government Strategy for 2020 which has recently been developed does not list health, and even less tuberculosis or HIV as one of the government’s priorities in the run up to 2020. The future EU priorities in EU-Moldovan cooperation are also not likely to address health, as those are based on the country’s pre-defined priorities. The annual EU envelope for Moldova is about €100-120 million. The EU contributed €50 million for the reform of the health system, only because Moldova identified health as a priority in EU-Moldovan cooperation in the previous budgetary cycle. EU budget support can only be given to government or international agencies, not to NGOs. One small project (half a million euros) on capacity building of non-state actors involved in the fight against AIDS under the Development Cooperation Instrument (DCI) thematic line ‘Investing in People’ is currently being implemented by an HIV NGO in Moldova. However, the Delegation was doubtful as to the positive impact of financial support to TB and HIV programmes in Moldova. They complained that no results were achieved in terms of TB and HIV control (rates haven’t declined) although millions of € have been invested in the country by the GFATM in now more than ten years. The EU delegation is a member of the CCM now for the second year. They seriously question the efficiency of the MoH in TB care and control. According to them, there are no serious reasons for asking money without providing attractive results. The MoH should have collected information on the impact of all the investments that have been made and know by now where the drawbacks are.

14 August: Joint Stakeholders Meeting – Chisinau

During the second day of the trip, the TBEC with the help of PAS, organised a Joint Stakeholders Meeting for Moldovan CSOs, patients organisation, the NTP, the MoH to meet the Coalition and to share information about their own TB work and advocacy activities. Around 20 participants were able to hear about the advocacy activities the TB Europe Coalition has undertaken. The discussion focused on the promotion of ambulatory treatment as one of the solution to decreasing TB rates in Moldova (the number of TB cases have slightly increased in 2011 compared to 2010). The Director of the NTP mentioned that the main obstacle was changing mentalities of those people who are involved in TB control since so many years. According to her, it would be easier to work with newcomers. However, it is obvious that hospital-based care is not effective, and the rate of nosocomial infections is high. The new pilot projects with community centres will help gather evidence that outpatient treatment not only saves money but also saves lives. The NTP sees the importance role of NGOs in improving treatment adherence but also in facilitating cultural changes in society. There is a general understanding of the progresses that need to be made at central level, but much more work to be done at local level as well. Mr Severin from the NGO AFI however mentioned that one of the main problems is the sustainability of external donor funding. So far most activities are funded by external donors (and mainly the GFATM). Two directions were CSOs can help is: to change the mentality of patients and to change the mentality of medical staff. PAS underlined that most joint stakeholders meetings which are organised deal with purely medical issues. One alternative would be to include advocacy and other structural issues at the agenda of such meetings. TB is a social disease, and everyone needs to be involved. SMIT patients’ organisation mentioned that it would be helpful to have a common plan for CSOs and governments with concrete activities.

The participants then discussed the added value of TBEC for Moldova. They envisaged the creation of a STOP TB Moldova or of a joint advocacy platform where CSOs could regularly meet, discuss and strategise how together they can better influence government, but also patients and medical staff. The CCM in Moldova is independent and has 2/3 of CSOs and 1/3 of government agencies. They also have 9 technical working groups. AFI suggested that a subgroup for CSOs and TB advocacy be created. The structure of such a group still needs to be discussed by the stakeholders. Advocacy and capacity building workshops would be most welcome.

We then headed to Balti, in the North of Moldova where we met with Feodora Rudiocova from Speranta Terrei and Oxana from SMIT patient organisation.

SMIT patient organisation was created two years ago in Balti by former TB patients who felt that they were not fully involved in the decision process by medical staff during their treatment. They felt TB patients needed to be empowered. Oxana, whom we met had TB for one year and then developed MDR TB during two years. Now her organisation gathers 9 people of which 7 are involved in projects funded by the Soros Foundation. They are visiting people affected by TB and raise awareness about the disease. They have also organised roundtables with local authorities in order to convince them that social and psychological support of patients was essential and to get some financial support to achieve this. They regularly visit hospitals and explain to patients what is available in terms of social services.

Speranta Terrei is a small NGO working in Balti. It is a sub-sub recipient of GFATM money. Feodora founded the organisation in 2006, she is a doctor. She first helped many patients in treatment: about 100 and saw it was successful. She now works with 25 to 100 volunteers who cover 57 villages. Each volunteer -or moderator as they call it- is in charge of 5 patients. Feodora’s biggest wish would be to start a 2-3 years project with sustainable funding.

15 August: Balti, North Moldova

On the third day of our visit, we met with the Mayor of Balti, Mr. Vasili Panciuc and with Mr. Veaceslav Batîr, director of the Health Department within the Balti Town Hall, visited the TB Dispensary and met with Speranta Terrei’s moderator and patients.

Both Mr. Panciuc and Mr. Batîr expressed their interest in helping create a local Stop TB partnership involving local actors such as Speranta Terrei and SMIT as well as local authorities and public health institutions. They also mentioned the difficulties in accessing international funds for local health systems, which according to them seem to be allocated on the basis of priorities established by the central government of Chisinau. While the local authorities can access funds for all sorts of projects in the benefit of the community, it appears that for anything involving health, the Ministry of Health of Moldova is responsible and allegedly, so far, the municipal hospital of Balti was not considered a priority. Both representatives of the local council acknowledged the importance of TB programs as well as the work being done by local NGOs such as Speranta Terrei and SMIT.

After the meeting at the town hall, we went to the local TB dispensary, which is an external section of the Balti municipal hospital. We met the head doctor, Mrs. Raisa Bărbuţă, who was very appreciative towards the NGOs who work with the TB patients and collaborate with the dispensary. However, she emphasised the need of a protocol that needs to be designed between the hospital and the NGOs, in order to assign each party clear responsibilities. Such protocol would help distribute beneficiaries between NGOs who can provide services according to their programs. Again, it was stated that the municipal hospital of which the TB dispensary is part, was not, so far, considered among the priorities for the Ministry of Health of Moldova.

The meeting with former TB patients took place later in the day, at the Speranta Terrei office. We also had the opportunity to talk to one of their “moderators” – people who ensure DOT for the most difficult patients who require special support (risk of default). The moderators not only follow the progress of the patient during treatment but also form a bond with them which tends to last even after they are no longer infected with TB. Although this might create dependency and perpetuate the status of the former patient as an assisted person, it’s also a way of ensuring that the beneficiary can be socially reintegrated. Some of the former patients are now employed by Speranta Terrei and continue to work with other patients. One example was Igor, a former patient who was also an inmate and who helps now other former inmates by referring them to the proper health services when tested and diagnosed with HIV and/or TB.

On the fourth day of the visit, we were interviewed by a journalist Victoria Tataru, who works as a consultant for PAS centre. She asked about our impressions on the TB situation in Moldova, and asked us to provide concrete advocacy successes at EU level. Here are the press releases that she published on different website:

PAS press release on TBEC visit (Romanian)

Interview with Fanny Voitzwinkler: “Advocacy can make a difference in TB Control”

Press release Institute of Phthisiopneumology (Romanian)

Press release on ONG.MD (Romanian)