Hetq speaks to Dr Stobdan Kalon, Head of Mission Doctors without Borders (Médecins Sans Frontières) in Armenia

What kind of programs is the organization Doctors Without Borders (Médecins Sans Frontières- MSF) implementing in Armenia?

First of all let me clarify a little bit of what we are doing here and what kind of an organization is MSF. MSF first came to Armenia in 1988 after the earthquake. As an international medical humanitarian organization that is non religious, non-political and we work in many countries on different kinds of health problems. In Armenia, we started with this earthquake program. After, we followed up with different kinds of programs depending on needs. After the collapse of the Soviet Union and there were many needs, especially for mental health and social support, Sexually Transmitted Diseases & HIV program etc that MSF supported. MSF also implement mental health and TB programs in Karabakh.

As regards our role, MSF is not a donor or technical assistance provider but a hands-on organization whose primary role is treating the patients, and in the process if required we also provide general assistance.

In the 1990s we opened the TB program in Karabakh. At that time drug resistant TB was recognized as a big public problem in all former Soviet Union countries. Armenia was one of the countries where we decided to work. Drug resistant TB requires intensive interventions for prevention, treatment and psychsocial support which is much more expensive and complex as compared to regular form of TB. Therefore MSF proposed starting a pilot MDR TB (multi-drug resistant) program which was the first of this kind in Armenia that started September in 2005. It was a close collaboration with the Ministry of Health (MoH) of Republic of Armenia where medical expertise, supply of drugs and consumables, logistics support etc came from MSF and while the MoH provided its staff and health facilities.

We started the program in two pilot districts in the city of Yerevan, Shengavit and Malatia-Sebastia, and in Abovyan and the Yerevan Dispensary. Different services were provided at these structures. At the level of the polyclinics, detection is done, and after the detection they were transferred to Abovyan. After the intensive phase is over they came back to the polyclinic for the continuation of the treatment. This was a model being introduced in Armenia. Subsequently the RA Ministry of Health obtained the approval from the Green Light Committee and funding support from the Global Fund.

The national TB program was still in its early stages and rather the whole system was still undergoing transition from Soviet to post Soviet phase- which was unfortunately taking too long. Due to the delay on part the National TB Program as there were many patients who still did not have access to the treatment, and MSF offered to support in further scaling up the program in close collaboration with National TB Program.

Which is the immediate MSF mission? The provision of drugs or other services?

We were providing drugs and provide expertise in diagnosis and treatment of drug resistant TB, we were also training the doctors and nurses, laboratory specialists, and we were also helping in transportation of samples from here to Germany. And when the Ministry received a Global Fund approval and technical approval from the WHO, "Green Light Committee" it was recommended for MSF to provide technical advice for the NTP in implementing the program. When the National TB Program's drugs and supplies arrived, towards the end of 2009 we planned together with the Ministry of Health to start a transition phase where they would provide drugs and consumables and MSF would provide technical advice and supervision at the sites of the project. At that stage the program expanded to cover whole of Yerevan city and Armavir marze.

Armavir, Kotayk, Ararat, Lori and Shirak Marzes have the largest number of drug rsistance TB patients therefore it was decided together with the National TB Program to cover those marzes first. Therefore MSF started a new project to cover Shirak and Lori in May 2010. While in Yerevan, we decided that from March 2010 all new patient enrolled would receive drugs from the National TB Program but MSF continued to supply drugs to patients still under treatment.

What's the reason for the delay of National TB Program?

I will say there are many factors mainly lack of organizational capacity of the National TB Program and the fragmented the TB control system.. The main decision-makers, implementers, and different structures like the Abovyan dispensary and the TB Cabinets in the Polyclinics- they need better coordination.

But isn't the whole structure supervised by the Ministry of Health?

Yes they do, but it's a technical work which has to done by the National TB program which needs further strengthening.

As far as I understood, you note the lack of professionals and qualified people in the structure.

Yes, in the managerial positions. Key issues that need to be addressed are organizational capacity and structural in nature. During the last year, when the new TB central office director Dr Balasanyan came on board, it has improved somewhat but still much work is to be done.

There were different people appointed to head the TB office, Vahan Poghosyan, Secretary of the Minister, and Minister Kushkyan himself supervised the program. Didn't you see any changes?

I would say it has been quite turbulent to have so frequent changes. I believe the Minister tried his best but they need to build a strong National TB Program which has to run the program. Some changes were made and some improvement seen under Dr. Balasanyan's leadership but there is a need to further strengthen it. I think Armenia has equally well qualified people. The new deputy minister Dr. Khachatryan who is involved in the TB program seems very motivated to improve the system. It is my hope that it happens.

But as mentioned for big improvements key organizational issues need to be resolved. There are some elements of Soviet style TB interventions like mandatory hospital treatment and patients being kept in hospitals for too long which are not recommended by WHO. There is also need to address human resources issues- recruiting and retaining skilled professionals especially in coordinating positions at central and regional levels, how many TB specialists are actually required, what activities to be delegated to family physicians, and the issue of inadequate salaries as we constantly get requests from staff in various facilities if MSF could provide incentives since they think their salaries are inadequate. Even Directors of some structures are requesting MSF to support their staff financially but we don't want to disrupt the system by introducing temporary incentives, its for the government to resolve these issues. These issues should be addressed as they are fundamental issues to better TB control.

One could take ideas from success stories from other countries- for example Georgia that is implementing the TB program very successfully. They had a good NTP Director providing effective technical leadership. Also they made serious reforms to discontinue discontinued obsolete Soviet style methods and practices.

Would you please evaluate the TB situation in the country? Which issues need to be resolved urgently?

The National TB Program is gradually improving and trying to address the TB epidemic but to be effective it needs to be done more rapidly.

Some problems are reflections of the limitations of TB tools at the global level – need for better diagnostics and better TB drugs- that MSF constantly advocates for. The Global Fund and German Development Bank have supported to get best possible diagnostics and drugs for the national TB Program. MSF has further supported on these issues. While diagnostics have improved over the years there has been no new drug discovered which is unfortunate. However MSF continues to advocate for these issues at the international level.

Do you think that Global Fund resources have been efficiently put to use here in Armenia?

I would say the National TB Program has been slow to utilize the funds. There is need for rapid well planned implementation to effectively address the TB epidemic in Armenia.