KOSOVO: BEYOND PORT TO PATIENT

Ferizaj, Kosovo - The patients arrive in the morning, before the town of Ferizaj shuffles awake. They come every workday, from both down the road and across uneven fields, to the only TB dispensary in the area: a one-story building that lost its roof and its windows to the war. Some have come alone; others have children waiting outside. Many have nowhere else to be in a province where up to half of the population is unemployed. And as store fronts open in the town that had one of the higher TB rates in Kosovo in 2002, one by one the patients are called to take their medicine.

Today, the sixth tuberculosis patient to arrive at the clinic is a 40-year-old father with no job, three children to feed and access to the finest quality TB drugs in the world. For the past three months, he has come to the Ferizaj clinic, where he does not have to pay for the TB medicine that would otherwise cost the equivalent of a doctor's one-month salary. The nurse watches while he takes the medicine and then records his name.

This morning's exchange, the last in a labyrinthine supply chain, is the reason why the GDF was created: to deliver low-cost, high-quality TB drugs to countries in need.

It is this exchange that is most frequently referred to among the GDF's achievements.

But awarding grants is only one part of the GDF's story. Less known is how the GDF, by going in country, may well have helped ensure that TB medicine can find its way to places such as Ferizaj.

The decision by the TRC in 2001 to become involved in on-the-ground drug management was born partly out of the realization that it is the patient who pays the price of lapses in the supply chain. At the time of the GDF's founding, however, few agencies had yet to venture into the field of drug management. The TRC reasoned that by sending consultants to monitor GDF drugs and identify bottlenecks, patients would stand a greater chance of gaining secure access to TB medicine. And as a mission to Kosovo last March demonstrated, it seems that with committed programme managers, dedicated ministries and strong partners, this reasoning can become a reality.

The GDF approach

Two years after the first delivery of GDF drugs arrived at Ferizaj's clinic, a team of GDF consultants who had initially surveyed Kosovo's drug system, John Holley and Dr Lucica Ditiu, returned to Kosovo for what they anticipated to be a straightforward mission. As they explained on the way to the central warehouse, the first stop on this mission, the Kosovo NTP, was "a dream." Partners such as Doctors of the World (DOW) and WHO have led the way in improving TB care and prevention, while the Ministry of Health has increasingly pledged its support to stop TB. Since 2001, Kosovo's active TB case-load has declined by as much as 30% while treatment outcomes have increased from 87% to 89% for new smear-positive TB cases.

Statistics like these might indicate that patients in Kosovo were at little, if any, risk of being turned away for TB medicine.

But the GDF monitoring approach goes beyond simply collecting statistics. Recognizing that a full assessment is costly and time-consuming, the GDF has developed a rapid survey approach that capitalizes on local knowledge. GDF consultants look for answers to the most important questions: are GDF drugs reaching patients? If not, why not? Doctors and policy-makers alike have commented that this approach is of value. As Dr Gazmend Zhuri of Prishtina Lung Clinic summarized, "The benefits of GDF monitoring are that we understand where the gaps are and what we need for TB with regard to drugs."

On the second day of the mission, this approach paid off when the GDF team and Dr Bahri Tigani, NTP Manager, unearthed a crack in the system that could - if not resolved - end up one day compromising patient access to treatment.

The problem surfaced during the team's meeting with the central warehouse manager, who explained candidly that he had no way of knowing where TB drugs went after they left his warehouse. The distribution system, was, in effect, running blind. Moreover, because there had been little communication between the pharmaceutical agency and the NTP, no one in the programme had realized that the warehouse had run out of one of the TB drugs.

Had the GDF mission not taken place, the shortage may not have been noticed until too late. Instead, by identifying the problem early, the team may have helped ensure that the programme could take appropriate measures. As one of the consultants announced, "Let's fix this."

Let's fix this

Most drug management (DM) experts will agree that "fixing" a distribution system requires a good deal of time, training, and funds - none of which are available to consultants during GDF missions. Instead, GDF consultants capitalize on the limited resources they do have at hand: TB and DM expertise, access to high-level decision-makers and the opportunity to engage with in-country partners.

Equipped with years of experience in programme management and TB control, Holley and Ditiu were able to provide immediate technical guidance and recommendations: from a mini training session on how to forecast drug needs and a demonstration on Management Sciences for Health inventory forms, to suggesting designs for a distribution schedule. Although such knowledge alone will not restore a weak drug distribution system, it can help jump-start the problem-solving process. For example, a 2004 survey found that roughly three quarters of countries approved for GDF support in 2001 have implemented recommendations for drug distribution and monitoring.

With access to high-level stakeholders, GDF teams can also ensure that the necessary political support is in place to take on larger tasks. After Holley and Ditiu presented their concerns about the distribution of TB medicine to the Permanent Secretary of Health, for example, he volunteered to provide funds and proposed organizing trainings at district level - perhaps even a DM study tour.

This type of response is indicative, in part, of how GDF missions can increase a programme's visibility and credibility. As Dr Xhevat Kurshani, Project Director of DOW Kosovo, explained, "There is no doubt that the international presence makes things happen." Last year, for example, the team quite literally boosted TB's presence at the ministry by recommending and securing an office space for the NTP Manager.

But perhaps the greatest contribution a GDF mission makes is simply to bring people together. In Kosovo, the GDF team brought together two strangers who had, for the past year, struggled independently to ensure that drugs could reach patients such as those in Ferizaj. By introducing the NTP and warehouse managers, the team helped address one of the bottlenecks: lack of human resources. "Until now," Dr Tigani explained, "I didn't have the right person to work with on this."

This type of collaboration characterizes many GDF missions, during which in-country partners can sometimes be heard referring to GDF consultants as "old pals"; consultants often finish delivering a piece of technical advice with, "It's up to you." In the words of one GDF DM expert, "A good consultant isn't some genius who arrives with a solution for every problem. A good consultant … is someone who can bring people together and get things going."

It is this type of support that distinguishes the GDF from other agencies and helps explain why, when Kosovo had to select an agency to procure TB drugs using GFATM funds, it chose the GDF: the same agency that set out to deliver drugs and returned to make sure they reached the patient.