The European Journal of Public Health Advance Access originally published online on April 26, 2006
The European Journal of Public Health 2006 16(6):609-614; doi:10.1093/eurpub/ckl027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Infectious diseases |
Fighting tuberculosis and HIV/AIDS in Northeast Europe: sustainable collaboration or political rhetoric?
Lars Rowe1 and Bernd Rechel2
1 The Fridtjof Nansen Institute, Lysaker, Norway
2 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK
Correspondence: Lars Rowe, The Fridtjof Nansen Institute, PO Box 326, 1326 Lysaker, Norway, tel: +47 67 11 19 16, fax: +47 67 11 19 10 e-mail: lars.rowe{at}fni.no
Received September 21, 2005, accepted January 31, 2006
 |
Abstract |
|---|
 Top Abstract MethodsResultsEpidemiological developmentsConclusionReferences |
|---|
Background: In April 2000, the Council of the Baltic Sea States established the Task Force on Communicable Disease Control in the Baltic Sea region (the Task Force). A successor structure, the Northern Dimension Partnership in Public Health and Social Wellbeing, was established in autumn 2003. This article, a follow-up study to a series of evaluations of the Task Force evaluation, examines whether the Northern Dimension has succeeded in developing the achievements of the Task Force and ensuring the sustainability of regional health collaboration.
Methods: The study is qualitative, relying on documentary analysis and semi-structured in-depth interviews with key actors. Relevant literature and key programme documents were consulted, and 
100 interviews were conducted.
Results: The short history of the Northern Dimension Partnership shows that many of the problems encountered in the Task Force are reappearing. Interstate rivalry, most prominent between Nordic countries, still hampers progress, with resulting scarce funding. The Partnership emphasizes the need to anchor future collaboration in centrally placed agencies in all participating countries. This is a time-consuming process, and has the inevitable effect of slowing down project work.
Conclusion: Although epidemiological data clearly illustrate the need for continued multinational support to communicable disease control in Northeast Europe, the above-mentioned factors impede progress in this respect. While there are good reasons for cultivating partnerships with Russian federal agencies in terms of sustainability, this focus does represent a loss of momentum that may be difficult to overcome.
Keywords: International Cooperation, Russia, Baltic States, Scandinavia, Communicable Disease Control
In this article, we investigate the potential sustainability of a major international health collaboration in Northeast Europe, the Task Force on Communicable Disease Control in the Baltic Sea region (hereafter, the Task Force), and the present state of its successor, the Northern Dimension Partnership on Health and Social Well-being (hereafter, the Partnership). The article is based on our previous evaluations of the Task Force1–3 and a study of the Partnership, undertaken in the summer of 2005.
The Task Force was established in April 2000 at the third Summit of Baltic Sea States in Kolding, Denmark, and comprised the 11 member states of the Council of Baltic Sea States (Denmark, Estonia, Finland, Germany, Iceland, Latvia, Lithuania, Norway, Poland, Russia, and Sweden) and the European Commission. It was meant to be an intensive short-term effort, responding to the widely acknowledged threat of communicable diseases in the Baltic Sea region. The choice of organizational model was motivated by the desire to avoid yet another cumbersome interstate bureaucracy.1,4 The basic idea behind the Task Force organization was to secure high-level political support from all participating countries, without losing sight of the grassroots level. While a hierarchical structure was set up, headed by appointed representatives of the 11 member governments and the European Commission, the main activity was concentrated on the ground, where medical experts at the local, regional, and national level were given ample opportunities to develop and implement projects. To secure communication between the operational and the political level, a group of senior health officials was established as an intermediate body between the highest political level and six topical programme groups.
The programme groups, consisting of medical experts of participating states, were the operational core of the programme. They covered the following main areas addressed by the Task Force:
- epidemiological surveillance,
- tuberculosis,
- HIV/AIDS and sexually transmitted diseases,
- antibiotic resistance and hospital infection control,
- primary health care, and
- subsequently established prison health.5
The Task Force managed to initiate and implement a substantial number of projects. Table 1 shows the number of projects across programme areas and countries at the end of 2003.
|
Although the Task Force did continue in 2004, not many new projects were initiated. About 50% of the 213 projects were carried out in Russia, reflecting its geographical size and large population, as well as the crisis experienced by the Russian health care system.1,6
A major health collaboration like the Task Force requires both political commitment and financial support from participating states. In its founding document, the Norwegian initiators envisaged the allocation of 
25 million for the first year of a proposed 3-year period.4 In its final report, however, the Task Force reported that only a total of 18–20 million had been secured over a period of 4 years, a figure including administrative expenses and allocations to projects, the latter amounting to 9–10 million.5 The actual willingness of participating Western countries to allocate resources to the Task Force has thus fallen far short of the aspirations of the programme's initiators.
The mandate of the Task Force officially ended in June 2004, with an expressed desire to continue along the lines that had been pursued so far, albeit under a new organizational structure, the Northern Dimension Partnership, which was created in October 2003. Our study has revealed a marked discrepancy between these ambitious intentions to continue the fight against communicable diseases and the present reality of international health collaboration in the Baltic Sea region. This article explores why the political rhetoric has not been followed by action and makes the case for sustained health collaboration in the region.
|
Methods |
|---|
|
TopAbstractMethodsResultsEpidemiological developmentsConclusionReferences |
|---|
This study is based on a qualitative approach, using two complementary research methods: a documentary analysis and a large number of semi-structured in-depth interviews with key stakeholders, which allowed for the triangulation of data. The documentary analysis comprised key programme documents and the scientific literature on the topic, identified through Pubmed/Medline, as well as general, predominately social science literature on post-Soviet developments. In 2002–2004 we conducted
100 interviews with purposively selected Task Force participants during field visits throughout Northeast Europe (a complete list of all interviewees can be found in1 and on file with the authors). The interviews were done by Lars Rowe and Geir Hønneland from the Fridtjof Nansen Institute, Oslo (both Russian speaking). In our follow-up study in the summer of 2005, a series of interviews with key actors in the then terminated Task Force collaboration added to our knowledge base. Interviews were conducted until information saturation was reached. All interviews in Russia were conducted without interpreter in the interviewees' mother tongue, while the other interviews were conducted in English, or, when possible, in the Scandinavian languages. |
Results |
|---|
|
TopAbstractMethodsResultsEpidemiological developmentsConclusionReferences |
|---|
Representatives of participating governments have expressed the view that the Task Force contributed to a greater political preparedness to prioritize the fight against communicable diseases.2 However, as already noted, the most crucial practical step, i.e. sufficient funding of further efforts, did not materialize to the anticipated extent.
One of the main obstacles to generating enthusiasm among participant states was interstate rivalry. Several interviewees pointed to the impeding effect of a predominately Norwegian leadership, despite the formally multinational character of the Task Force programme.1,2 Although the Norwegian readiness to take a leading role was generally received positively by other Task Force countries, it seems to have affected the willingness of other states to invest financial resources into the collaboration. Apparently, the national funding agencies worried that they might lose prestige by funding projects in a programme that was perceived as ‘Norwegian’. Norway's initiative and leadership in establishing the collaboration soon became a seemingly insurmountable obstacle to the realization of a well-funded programme. The result was that Norway, as one of seven potential funding states, provided about 65% of the total project funding of the Task Force. However, many structures for bilateral collaboration were already in place in the region before the Task Force was initiated. Due to the fear of losing prestige and ownership over particular international endeavours, many of the Western participant states have refrained from including their projects in the Task Force coordinating database.
The relative lack of political or financial commitment, however, did not halt initiatives to continue the fight against communicable diseases. With the aim of picking up the Task Force legacy and expanding the health collaboration to comprise non-communicable diseases, the Northern Dimension Partnership on Health and Social Well-being was created in October 2003. The Partnership added France and Canada to the 11 Task Force countries and included 8 partner organizations. It set up an organizational structure paralleling the Task Force model.7 At the time of writing (January 2006), the partnership structure was well in place, but the work initiated by the Task Force seems to have ground to a halt. There are several reasons for this failure.
First, the readiness among Western partners to fund activities is still very limited. The heart of the Partnership, the Secretariat, is understaffed, and currently consists only of a Swedish chairman and his Lithuanian adviser working in Stockholm, and a Russian part-time consultant in St Petersburg. Perhaps the most visible effect of scarce funding is the failed attempt to develop a coordinating database. The envisaged database is meant to contain information on all existing and planned projects, providing a clear picture of the ongoing work in the region and where more efforts are needed. In addition to its coordinating function, the database is meant to have a motivating effect on potential funding agencies. The realization of the database is expected to cost around 300 000, a sum which has not been provided by any partner so far.
Second, the Partnership, designed as a more sustainable and longer-term effort than the Task Force, puts more emphasis on political groundwork. Substantial effort has been invested in establishing a firm basis for the collaboration in the central ministries of participating countries. As the Partnership has expressed the ambition to anchor the health programme internally in the Russian federation, much attention is being paid to the Russian Ministry of Health and Social Affairs. This effort aims to achieve better planned health interventions, as well as a firmer political basis for the Western-Russian collaboration. The Partnership's ‘central approach’ has its flaws. Dealing with Russian central authorities can be a time-consuming process, as there are many interest groups and Russian and Western objectives might be contradictory. The risk of losing momentum is considerable.
In contrast, the Task Force had a stronger regional focus and did not always involve Moscow. In fact, many of its projects were joint ventures between the concerned regional administrations in Russia and Western donor agencies.1 This approach is more efficient in yielding quick results ‘where it matters’, but has a downside when it comes to sustainability, as any effort to establish a long-term and sustainable collaboration with Russia also needs to be firmly embedded in the central agencies in Moscow.
As noted above, one of the main achievements of the collaboration was the establishment of professional medical networks in the region, i.e. the programme groups. Many Task Force participants expressed their hope that the emerging Partnership would be able to keep the networks established by the Task Force alive.
The structure and aims of the Partnership were to a large extent based on the Task Force model, and three of the Task Force programme groups (on HIV/AIDS, primary health care, and prison health) have been incorporated in its structure as ‘expert groups’. In addition, a new ‘expert group’ on non-communicable diseases has been established. The mere incorporation or establishment of expert groups, however, is not a proof of continued activity. To keep the networks alive, there is an obvious need not only for money but also for motivating content, i.e. new tasks for the networks to solve, in order to justify the time and costs of active participation. Although representatives of the three expert groups formally incorporated into the Partnership maintained that there is much left to do and expressed the desire to continue their activities, it is, at present, very unclear if they will be able to do so. So far, the ‘expert groups’ have not been given any tasks, and funding for their meetings has been scarce. One exception is the HIV/AIDS group, which has acquired money through an alternative channel, the Finnish agency STAKES (the National Research and Development Centre for Welfare and Health) as part of the Finnish work under the Barents Health programme.
In response to the obstacles with which the Partnership is confronted, the head of the Partnership Secretariat, Lars Blad, resigned from his position in November 2005. His ‘informal letter of resignation’8 is illustrative of the problems experienced by the new health collaboration. Among the reasons cited by Blad for his resignation was the lack of political and financial commitment. He emphatically stated that he is ‘[...] still too much of a doctor to accept to waste [his] time and others money by taking part in an empty show'. This mirrors the frustration frequently expressed by our interviewees in June 2005 that next to nothing happened to sustain the medical networks after the termination of Task Force.
|
Epidemiological developments |
|---|
|
TopAbstractMethodsResultsEpidemiological developmentsConclusionReferences |
|---|
The epidemiological trends underline the need for international health collaboration in the region. At the time of writing (January 2006), communicable disease trends in Northeast Europe offer little reason for optimism. A decreasing HIV incidence rate has been recorded in most locations since 2001, but rates continue to be at a very high level, although prisoners and military personnel are not always included in the official data (figures 1
–3).
|
|
|
Registered rates of new tuberculosis cases in Northeast Europe have increased markedly since the beginning of the 1990s.11–13 Most countries have registered a decline in recent years, although the incidence rate increased again in Lithuania in 2003 and remained 14 times higher in the Russian Federation than the average of the Nordic states in 2002. In Northwest Russia, the reported incidence has stagnated or continued to rise in most territories since 1999 (figures 4 and 5).
|
|
When considering these trends, it should be kept in mind that the new system of case finding, recording, and reporting associated with the gradual introduction of the DOTS strategy in the region makes comparisons with previous incidence rates problematic.4,14–16 Incidence rates in Northwest Russia would be even higher, if the prison sector was included in the statistics, as it greatly contributes to the spread of tuberculosis in the region.
Are the improvements in incidence rates of tuberculosis and HIV—in those localities where they occurred—a result of the Task Force initiative? While the Task Force contributed to the fight against communicable diseases in Northeast Europe, it was only one factor among many others.1,17 As has been recognized by the Task Force itself, economic development is ‘probably the most effective intervention’.4 In the places where a decline of HIV and tuberculosis incidence rates was observed, the decline generally predated Task Force initiatives, so that an attribution of the decline to the Task Force would be highly questionable.
A broader problem in the region is the poor quality of available epidemiological data.18 Even across widely used international datasets on the incidence of tuberculosis and HIV/AIDS in the region, significant differences exist.3 While anonymous testing has now been introduced, there is still insufficient access to voluntary counselling and testing in the region19 and private health care providers do not always report test results to national surveillance systems.15 Poor laboratory diagnostics, inadequate training of personnel, weak health information and surveillance systems, and the stigma associated with tuberculosis and HIV/AIDS contribute to distorted epidemiological statistics.19–24
|
Conclusion |
|---|
|
TopAbstractMethodsResultsEpidemiological developmentsConclusionReferences |
|---|
As illustrated by epidemiological trends, continued efforts to combat communicable diseases in Northeast Europe are needed. In its founding document, the Task Force set out the goal of reducing HIV incidence rates to 2 per 100 000 population by 2010 and tuberculosis incidence rates to 20 per 100 000.4 Based on recent trends, these goals are at best unlikely to be achieved.
In the overall effort to permanently reduce the burden of HIV/AIDS and tuberculosis in the region, strong medical networks are of great importance. So far, the networks produced by the Task Force have not been given sufficient organizational and financial support. Although personal contacts in the region have been established and will to a certain extent be maintained irrespective of the development of the Partnership, the collaboration at the professional medical level is likely to fade out if further networking is not actively funded. This holds particularly true for the regional Russian medical community, which is especially prone to isolation from non-Russian professional contacts. Letting the established networks whither away must be considered a lost opportunity.
While the Task Force had only a limited duration, the new Partnership must be built on stronger foundations. To achieve this, considerable obstacles must be negotiated. The interstate rivalry on the Western side of the Partnership will, most likely, continue to impede the process. The only way to overcome this obstacle seems to be an establishment of a collaboration that is truly multinational and can function as a prestigious focus of health projects in the region. Only then can one expect to see any substantial results in the form of Western funding. Presently, even the small contribution needed to establish a database of regional health projects (300 000) seems to be unattainable. This illustrates how far potential funding agencies are, at present, from allocating the necessary financial means.
Another challenge is to reach a reasonable compromise between the Western states and the central government of the Russian Federation. There is a distinct tendency among Nordic agencies to be oriented towards their bordering regions. Many Russian counterparts are rightly worried about this process leading to some regions developing more advanced health services merely due to their geographical position next to a ‘rich Western uncle’, whilst other regions are left behind. Western partners must take this concern seriously. The Nordic preoccupation with areas in their vicinity, however, is understandable. Spending of government funds in these areas are easier to justify than in, for example, remote Siberian areas. Russian authorities must therefore to some extent accept the Western preference for establishing health projects in bordering regions, while developing partnership and project opportunities that could channel more Western expertise and funding into other, more remote regions.
Returning to the question posed in the title of this article, there is little doubt that the ambitious aims that the Partnership has set itself in its founding declaration—to ‘contribut[e] to intensified co-operation in social and health development’, and ‘to enhance co-ordination of international activities within the Northern Dimension area'25—must be at present considered to be of primarily rhetorical value. However, the declaration also states that the Partnership is ‘an evolving process’. It should be noted, that the most recent annual conference of the Partnership in November 2005 did agree to allocate some funding for further activities, including support to the expert groups.26 While we can therefore not exclude that the Partnership will evolve into a fully functioning and generally accepted coordinating body, the slow start does not bode well for the future of multinational collaboration in communicable disease control in Northeast Europe.
Key points
|
|
Acknowledgments |
|---|
The authors are especially grateful to their interviewees, to Vibeke Rosvold Gundersen at EpiNorth for updated data on the region, and to Elana Wilson at the Scott Polar Research Institute, Cambridge, UK, for her useful comments on the manuscript. The Norwegian Ministry of Foreign Affairs funded the work on this article.
|
References |
|---|
|
TopAbstractMethodsResultsEpidemiological developmentsConclusionReferences |
|---|
1 Hønneland G, Rowe L. Health as International Politics: Combating Communicable Diseases in the Baltic Sea Region. Ashgate, 2004.
2 Rowe L. Report from the Steering Committee for Evaluation of the Task Force on Communicable Disease Control in the Baltic Sea region. Oslo: Fridtjof Nansen Institute, 2004
3 Rechel B, McKee M. Learning Lessons from the Experience of the Task Force on Communicable Disease Control in the Baltic Sea Region. Programme Evaluation. London: London School of Hygiene & Tropical Medicine 2004.
4 Task Force. Background Document "Healthy Neighbours": Task Force on Communicable Disease Control in the Baltic Sea Region, 2000.
5 Task Force. Final Report to the fifth Baltic Sea States Summit, Laulasmaa, 21 June 2004: Task Force on Communicable Disease Control in the Baltic Sea Region, 2004
6 Hønneland G, Rowe L. Western versus post-Soviet medicine: fighting tuberculosis and HIV in Northwest Russia and the Baltic States. J Commun Stud Trans Politics 2005; 21: 395–415.[CrossRef]
7 ND Partnership. Northern Dimension Partnership. Public Health and Social Well-being. Available at: http://northerndimension.custompublish.com/index.php?cat?=29143. 2005
8 ‘Informal letter of resignation’, signed by Lars Blad, dated 15 November 2005. On file with the authors.
9 WHO. WHO Regional Office for Europe health for all database, June, 2005
10 EpiNorth. EpiNorth website: epidemiological data. EpiNorth; 2005. Available at www.epinorth.org.
11 Task Force. Report of the Programme Group on Tuberculosis: Task Force on Communicable Disease Control in the Baltic Sea Region, 2004.
12 WHO/IUATLD. Anti-Tuberculosis Drug Resistance in the World. Report No. 3. Geneva: The WHO/IUATLD Global Project on Anti-Tuberculosis Drug Resistance Surveillance, 2004.
13 Blystad H, Blad L, Tulisov A, et al. Status on Some Important Infectious Diseases in Northwest Russia the Nordic and Baltic Countries 1999-2003. EpiNorth 2004; 5/6(2004/2005(4/1)).
14 Blystad H, Blad L, Giesecke J. Surveillance and trends of priority infectious diseases in the Baltic Sea region. EpiNorth 20023
15 Riedner G, Dehne KL. Recent declines in reported syphillis rates in eastern Europe and central Asia: are the epidemics over?. Sexually Transmitted Infections 2000; 76(5): 363–365.
16 Task Force. Report on TF project #69. Monitoring visit 22–27 September 2002 Task Force on Communicable Disease Control in the Baltic Sea Region, 2002
17 Task Force. Annual Report 2002: Task Force on Communicable Disease Control in the Baltic Sea Region, 2003
18 Bernitz BL, Rechel B. HIV data in Central and Eastern Europe: fact or fiction? In: Matic S, Lazarus JV, Donoghoe MC (eds), HIV/AIDS in Europe. Moving from death sentence to chronic disease management. Geneva: World Health Organization, 2005
19 UNDP. Reversing the Epidemic: Facts and Policy Options: United Nations Development Programme, 2004
20 UNAIDS/WHO. AIDS epidemic update December 2003 United Nations Programme on HIV/AIDS/World Health Organization, 2003
21 STIGUP. Report for the project "Improvement of the prevention and control of STI in Leningradskaya Oblast" 2002. Uppsala: Sexually Transmitted Infections Uppsala Group (STIGUP), 2002.
22 STIGUP. Project report "Improvement of the prevention and control of STIs in Estonia" 2002. Uppsala: Sexually Transmitted Infections Uppsala Group (STIGUP), 2002
23 Task Force. Report on Task Force Project HIV 10 "Improvement of the Prevention and Control of STIs in Lithuania": Task Force on Communicable Disease Control in the Baltic Sea Region, 2004
24 Perelman MI. Tuberculosis in Russia. Int J Tuberculosis Lung Dis 2000; 4: 1097–103.
25 ND Partnership. Declaration Concerning the Establishment of a Northern Dimension Partnership in Public Health and Social Wellbeing, 2003
26 ND Partnership. Partnership Annual Conference (PAC), 18 November 2005. Accessed on the partnership website (http://www.ndphs.org/)
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  B. K. Bernitz Communicable disease policy development in response to changing European political frontiers in Finland, Norway and Sweden Scand J Public Health, November 1, 2008; 36(8): 875 - 878. [Abstract] [PDF]
|
|
|
|
 |
|
 D. Radin World Bank Funding and Health Care Sector Performance in Central and Eastern Europe International Political Science Review/ Revue internationale de science pol, June 1, 2008; 29(3): 325 - 347. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||