March 9, 2010—As soon as she discovered she had tuberculosis (TB), Maria Stepanova made preparations for her own death. She wept inconsolably and bought herself a pretty outfit to wear in her coffin. As a sanitation worker scrubbing floors at a tuberculosis dispensary, she knew first-hand the heavy toll exacted by the disease in Russia. Russia’s TB mortality rate is among the highest in Europe. In Novosibirsk, the capital of Siberia where Stepanova lives, almost one in three TB infections is fatal.
“I knew how it all finishes. I was surrounded by death,” she says three years later.
When a World Bank team visited Novosibirsk as part of project supervision, Stepanova, a chirpy 46-year old carefully attired against the autumn chill, was alive and well. Her first grandchild had been born recently, she had resumed her hospital work and she was confident that the rigorous anti-TB treatment she followed had rid her body of the debilitating disease.
Spurred by a TB and HIV/AIDS Control Project supported by a $150-million loan from the World Bank over 2003-2008, Russia’s health care system adopted a more rigorous strategy for the diagnosis and treatment of tuberculosis, both among civilian populations and in the prison system across the country.
The strategy encourages earlier and more accurate detection of TB cases through sputum smear microscopy, standardized treatment regimens of 6 to 8 months under direct observation (to assure compliance and avoid drug resistance), and the maintenance of a standardized recording and reporting system.
This strategy, promoted with technical assistance from the World Health Organization, represents a momentous “paradigm shift for Russia,” according to the World Bank project’s team leader Patricio Marquez.
Additionally, the project supported the development of guidelines and protocols in line with international standards for HIV/AIDS prevention, diagnosis, treatment and follow-up, while strengthening the public health laboratory and surveillance systems.
TB Deaths, HIV Rates Drop
TB mortality in the total population decreased by 15.4 percent from 2006 to 2007, and among prisoners – the most affected group – TB deaths dropped by 37.5 percent. There was also a 72.7 percent increase in TB patients receiving the standardized treatment regimen, including directly observed treatment. The rate of increase in HIV prevalence dropped by 7.7 percent between 2006 and 2008. HIV-positive infants born to HIV-infected women decreased from 13.6 percent to 9.8 percent between 2004 and 2008.
According to Svetlana G. Safonova, Chief, Medical Administration of the Federal Correction Service (Prisons) of the Russian Federation and doctor of biological sciences, “The best way to tell this story is by the results. During the last five years of its implementation, the project helped reduce TB prevalence rate by 20 percent and TB mortality rate by 33 percent in the institutions of the Federal Correction Service. By the end of 2008, overall implementation of the TB/AIDS Control Project resulted in increasing coverage of TB patients by bacteriological tests up to 95 percent.”
Restructuring Health Care Delivery
In parallel, Russia’s Health Reform Implementation Project, funded as a 2003-2008 pilot project in the Chuvash Republic and Voronezh Oblast, along with support at the federal level, tested new approaches to restructuring health service delivery, for later replication in other regions.
A third project in the Chuvash Republic , launched in 2009 in partnership with the International Finance Corporation (IFC) under a sub-national financing mechanism, is building capacity to prevent and treat cardiovascular diseases and injuries—the leading killers in Russia. Health service improvements contributed to decreased infant mortality rates and increased life expectancy of the population (above the average in Russia) in the two pilot regions.
The Bank is also providing technical advice on a fee-for-service basis to regional governments such as in the Khanty-Mansiysk Autonomous Okrug and the Kirov Oblast, while sub-national lending is geared to help restructure the organization of health service delivery, as is currently being discussed in the Vologda Oblast. The use of these new mechanisms is highly relevant to other middle-income countries.
Besides national institutions, the World Bank has established partnerships and mobilized additional resources by working with a number of international agencies on health sector improvement in Russia, including the World Health Organization, UNAIDS, Global Fund to Fight AIDS, Tuberculosis and Malaria, Canadian International Development Agency, US Agency for International Development, US Centers for Disease Control and Prevention, International Transport Forum, OECD, U.K Department of Health, Public Health Agency of Canada, Finland National Institute for Health, Bloomberg Initiative to Reduce Tobacco Use, the UK National Institute of Health and Clinical Excellence (NICE), and the Bill and Melinda Gates Foundation.
According to Marquez, “The real value of the World Bank Group involvement in middle-income countries such as Russia is to help foster partnerships, disseminate knowledge and promote evidence-based innovation.”