Mandate

The Task Force shall:

• Review the recommendations and the background documentation for concerted action in the field of communicable disease control in the region.

• Develop instruments for the implementation of the recommendations.

• Oversee the implementation of recommendations.

• Establish and conduct an evaluation of the entire initiative.

• Report to the CBSS Summit 2002 (subsequently 2004).

• Prepare for the end of the Task Force and make recommendations for the continuations of activities when the mandate expires.

Members of the Task Force:

Ib Valsborg, Permanent Secretary, Denmark

Katrin Saluvere, Director General, Estonia

Ronald Haigh, Head of Unit, EU Commission

Jarkko Eskola, Director General, Finland

Reinhard Kurth, President, Germany

Haraldur Briem, State Epidemiologist, Iceland

Viktors Jaksons, Minister, 2002

Signe Velina, Deputy Director, Latvia

Eduardas Bartkevicius, Vice Minister, Lithuania

Lars Erik Flatø, 2001

Kristin Ravnanger, State Secretaries, Norway (Chair)

Andrzey Ryz, 2002

Miroslaw Manicki, Vice Ministers, 2003

Wiktor Maslowski, Adviser for the Minister of Health, Poland

Georgy M. Petrov, Vice Minister, 2001

Viktor Maleev, State Infectionist, Russia

Erik Nordenfelt, Professor, Sweden

The Task Force Special Representatives were responsible for political co-ordination and oversight of the entire initiative. The Special Representatives were also given the responsibility to ensure that agreed procedures for prioritisation and use of economic resources were followed, and to mobilise national resources and commitment during the lifetime of the initiative. One further aspect of their work was related to the enlargement of EU in May 2004, when the ‘political geography’ of the whole area changed. In this sense, the activities of the Task Force also took cognisance of the need to support accession priorities as well as to encourage collaboration with the Russian Federation, in response to the impending extension of the frontier with EU.

Background documents

The plan of action developed by the Task Force is described in the background document «Healthy Neighbours». This document also gives a brief overview of the health situation in the Baltic region and discusses elements of public health strategies. Finally, it sets out the scope and principles for international cooperation in combating infectious diseases .The document lists five programme areas, that were confirmed by several expert panels on project development: Surveillance; Early Warning and Vaccinations; Tuberculosis, HIV and STI (Sexually Transmitted Infections); Antibiotic Resistance and Hospital Infection Control; and Primary Health Care Services. Later, at the Summit in 2002, a further programme area on Prison Health was added.

Regarding the organizational structure of the Task Force, the Programme Groups for each of the programme areas worked as the prime engines in project development. The tasks and responsibilities of International Technical Advisers – ITAs – and a Group of Senior Health Officials – GSHO – were laid out in a subsequent document entitled «Implementation – Down to Earth», which also can be found at the website mentioned above. In 2001–02, the Task Force expanded further with the addition of working groups and advisers on training in public health and health sector reform.

It was decided to use the Logical Framework Approach, an internationally recognized tool in development project planning, as an obligatory frame for all projects. All Task Force projects were to be entered into the database and published on the Task Force website, and targets reported by the project leaders as they were reached. The website was also used by the members of the Programme Groups to draft projects. Training courses in Logical Framework Approach were given. In all, 223 projects were registered. Of these, 61 were proposals or drafts which were not finalised, or were closed. In all there were 36 projects registered for Estonia, 35 for Latvia, 45 for Lithuania, 17 for Poland and 105 for the Russian Federation.

Over time, until end of March 2004, 162 projects were posted as «approved» or «completed» by the groups. Of the 129 «approved» but not yet completed projects, there were 105 that had full or partial funding and were in progress. In addition, there were at this time 33 projects that were completed. This is a remarkable outcome, and reflects the general proactive attitude in the Task Force.

Guiding principles

The Task Force set up a decentralized organizational structure, which granted very high degrees of autonomy to the Programme Groups, i.e., the panels of experts from participating countries. This approach laid considerable responsibility and authority on the project leaders. The logical framework and the reporting on the homepage, in addition to possible separate reporting to donors, were the ties intended to keep the whole initiative together.

The task of monitoring the database was outsourced to an academic institution which reported regularly to the Secretariat. These reports also formed the basis of the oversight performed by the GSHO and the Task Force authority itself. This was for many a new approach and not always readily understood. Some actors expected, even would have preferred, to work to a more traditional, hierarchical model, with a central authority directing, instructing and distributing funds from the top. But the Task Force decided early on to avoid yet another bureaucratized intergovernmental organization, and clearly wanted to reduce the potential for donor-driven projects.

Sustainability was an important guiding principle. Projects should be anchored with local authorities, who were best capable of taking local circumstances into account, and could also be expected to mobilise their parts of the budgets, in particular salaries, premises and expendables, in view of continued activities once the international collaboration came to an end.

The core elements of the collaboration thus rested on the transfer of knowledge and technology and a shared understanding of the problems, contexts and solutions. One-time investments in equipment were underwritten by external partners, and the guiding principles were flexible enough to allow exceptions, when there was an obvious need, for example to renovate premises in prisons.

Organization of work

The collaboration was based on the agreed objectives set out in the background document. Each Programme Group took these as starting points in their work to develop more specific project models, following the logical framework, in their various fields. Guidelines were then developed on how to develop concrete projects, and International Technical Advisers were placed at the disposal of initiators of new projects.

Project proposals and drafts were to be discussed, modified and finally approved by the Programme Groups. Although projects were approved, that did not necessarily entail budget approval.

A Group of Senior Health Officials, senior government officials from each country and the European Commission, were appointed by the Task Force members to oversee programme developments and project funding. The meetings of the GSHO were open to observers from WHO, UNAIDS and other organizations. The large majority of approved projects did, in the end, receive funding, either wholly or partially. Once projects were under way, project leaders were expected to report on progress through the database.

In addition to project development and implementation, many other activities were taking place. Site visits, discussions on best practices and guidelines, policy formulations, advocacy, training activities, participation in conferences and professional meetings which in par are not listed. Specifically, the participants in the Task Force and its sub-elements participated in the development of a network for training in public health, the development in pilot schemes for health sector reform, in the evaluation of the Task Force and its activities, and in laying of a foundation for an EU Northern Dimension for Public Health and Social Well-being.

Funding

It is estimated that the total cost of the Task Force is in the range of 18–20 million €in direct expenditures. This estimate only takes into account funds spent directly on projects, training, meetings and the Secretariat, including monitoring and evaluation. The direct financing, or explicitly earmarked funds for the Task Force projects as reported in the database, came in at a little short of 9 million €. There has, however, been some underreporting to the database at the time of the present writing, for which there are several causes. Either reporting has been delayed, or only partially filed, for instance, only the early instalments, or the funds have not reached the project leader at the time the records were filed. When financing goes through a Western NGO(Non-governmental organizations), the project leader often only sees part of the contribution. There are examples of cases in which more than 60 per cent of disbursed funding has been used to cover salaries, travel expenses, overheads and other expenses incurred by the NGO in question.

Denmark reports a direct contribution of 625 000 €, divided as follows: Direct project support: 322 000 €, ITA: 201 000 €, evaluation: 32 000 €, Task Force related meetings including travel expenses: 70 000 €. Finland reports a direct contribution of 1 244 776 €, divided as follows: Direct project support: 759 304 €, ITA: 420 776 €, Task Force related meetings: 64 696 €, in addition travel expenses which are not recorded. Germany reports a direct contribution of 357 800 €, divided as follows: Direct project support: 305 800 €, networking (travels, meetings): 52 000 €. Iceland reports a contribution of 361 500 €, direct project support 40 000 €, ITA and networking: 321 500 €. Norway reports a direct contribution of 8 684 000 €, divided as follows: Direct project support: 6 515 000 €, networking: 1 054 000 €, evaluation: 340 000 €, monitoring: 150 000 €, secretariat: 625 000 €. Sweden estimates its total contribution to 4 653 000 €. Direct project support: 2 075 000 €, Swedish East Europe Health Committee: 1 989 000 €, Task Force related meetings: 108 000 €, ITA: 266 000 €, networking: 215 000 €. The Unites States contributed $ 150 000 towards the cost of the ITA for HIV/AIDS.

The amounts provided by country in direct project support, as reported, are (in €):

There was also funding for other ongoing projects, i.e., initiatives not included under the Task Force umbrella. Examples are the Finnish Office for the Collaboration with the Nearby Areas, Swedish Eas Europe Health Committee (as mentioned), Norwegian prison health support, projects under the Nordic Council of Ministers and the Barents Health Programme, all sizeable programmes. It is not always possible to draw a sharp line between Task Force-related projects and such other, independent projects.

It is also important to note that several projects received direct or indirect support from subsidies under the EU Public Health Programme. There has been an effort, in particular by the EU Commission, to provide and share technical knowhow on EU matters within the Task Force framework, including access to EU funds such as PHARE and TACIS. A two day training course was organised in October 2001 on this issue.

Several other types of programme costs are not accounted for, such as staff costs, equipment and other expenditures for participants that have not been remunerated. The database has registered 533 names of persons making an active contribution to the work of the collaboration. These are professionals across all involved areas who have given hundreds of working hours without recompense from their usual employers to take part in Task Force projects and other activities. To put a figure on all of this work would be pure speculation.

In addition, a number of training courses and professional consultations other than those included in specific projects were organized, explicitly related to the work of the Task Force. We mention here Sigtuna 2 Conference, October 2000; the Stakeholder Conference on Training in Public Health, Trakai, October 2001; Tuberculosis among Prisoners, St. Petersburg, November 2002; Understanding the System of Epidemiology and Surveillance of Infectious Disease around the Baltic Sea, Moscow, June 2003; the Baltic Region Conference Together Against Aids, Riga, September 2003; and finally support to the Nordic-Baltic Society of Infectious Disease, in particular the Congress in Palanga, June 2004. These and other smaller conferences were funded, fully or in part, through the Task Force system. Total cost figures are not available for travel expenses and Task Force related meetings (Task Force, GSHO, Programme Groups, and Network for training and similar) because the expenditures of host countries were impossible to record. There is therefore no comprehensive statement of these costs. ITAs (including travel expenses) were funded by Finland, Denmark, Iceland, Norway, Sweden and the US. Other expenditures, including the participation at CBSS meetings, contributions towards the Northern Dimension Partnership in Health and Social Well-being and efforts to promote health sector reforms, have not been fully recorded or compiled.

Main results

Originally, the Task Force, as a new health-related initiative, was given a high political priority, confirmed not least by the appointment of special, personal representatives of Heads of Governments to the Task Force group to guarantee and maintain close contact with their respective Prime Ministers.

As stated in the evaluation report, the promise of that auspicious start failed to materialize, and the Task Force Group would never attain the political influence envisioned for it. Member countries only in part displayed sufficient political commitment (in the form of funds) and not all did appoint people of political stature, empowered to make the necessary decisions (how to use funds).

If political commitment is counted only in Euros, then the results of the Task Force must be described as modest, given the magnitude of the threat posed by communicable diseases. If we look at the results in terms of the raising of political awareness of the threat of HIV/AIDS, TB and other communicable diseases in the respective countries, its incorporation on the agendas of Governmental bodies, the bilateral discussions between Prime Ministers, the changes in national neighbourhood cooperation policies and funding, and the increase in national budgets to combat communicable diseases, then we must say that the collaboration was remarkably successful. That said, translating policy changes into action takes time and since the lifetime of Task Force has been relatively short, the full impact is yet to be seen.

The Task Force laid the basis for closer collaboration at the political level, something we now see in practice with the establishment of the Northern Dimension Partnership in Public Health and Social Wellbeing, in which networks created within the Task Force framework play an important part.

As to meeting the original concerns of the Sigtuna meeting, i.e., to mitigate risks and reduce the incidence of communicable diseases, the general picture is one of success. Incidence is either flattening out or declining; thanks to improved living conditions, national programmes, individual commitment and, we hope, in part, international collaboration led by the Task Force.

In summary, the Task Force has been instrumental in:

• Raising political awareness of the problems related to communicable diseases.

• The adoption of international guidelines in the agreed priority/programme area.

• The formation of a large project portfolio in the programme areas, improved surveillance and decline in the incidence of infectious diseases.

• Improving understanding of project design and management.

• The establishment of a wide network of experts and health and other officials.

• Cementing a basis for future collaboration in public health training.

• Initiating a method to model systems that will lead to reforms in the health sector and expansion of primary health care provision.

• Providing the groundwork on which the EU Northern Dimension Partnership for Public Health and Social Well-being can be developed.

• Adding to the literature through the innovative design for collaboration and project development, and subsequent careful evaluation.

Specifics from Programmes

This chapter reports only selectively and briefly on each Programme. Detailed information can be found in the Programme Group reports, available at www.baltichealth.org.

Tuberculosis

The work of the Programme Group on Tuberculosis was, at the outset, much facilitated by the work of the NO-TB Baltic initiative a few years earlier. Dr. Tone Ringdal was coordinator for this work, and became the chair of the Task Force Programme Group. She died in a car accident in June 2002. This was a great loss to the group in particular, and, of course, the Task Force. The loss of Tone Ringdal and her personal and professional contributions were much regretted.

The stated objective for this group was to reduce the burden of tuberculosis in each country to the European average (less than 20 per 100 000) and prevent the further proliferation of multi-drug-resistant tuberculosis (MDR-TB).

The group had an International Technical Adviser, funded by Iceland and Norway (travel expenses), at its disposal. Most of the group members saw their work as a continuation of the above mentioned NO-TB Baltic Project, which had been generously funded by the five Nordic countries (equivalent to almost 3 million € today) from 1998 to 2000.

The group reports that the ideas of the Logical Framework Approach and the electronic database were received with limited enthusiasm. Many were convinced from the start that it was a waste of time and it should be up to individual project teams to plan and monitor activities as they saw fit. The group also reports that financing was a central concern. That said, all the projects were funded, raising the question of saturation and indicating that needs are met through the ongoing activities.

The group met ten times, the last being in May 2003. The group is not inclined to continue as a group beyond the lifetime of the Task Force. The group approved 26 projects, 22 of which received funding and are either already finalized or in progress. The group decided not to arrange peer reviews.

A key component was bringing the tuberculosis services in alignment with the DOTS (Directly Observed Treatment Short-course) programme recommended by WHO. The tuberculosis project receiving the highest funding provided by the Task Force (622 000 €), was support to the national TB programme in Lithuania. It will make DOTS available throughout the country. In Kaliningrad, projects are under way to accelerate the introduction of the DOTS programme and to improve detection of tuberculosis among HIV positive patients. Other Task Force projects aim at strengthening tuberculosis services in primary health care (Latvia, Karelia, St. Petersburg), provide social support to MDR-TB patients to increase adherence to treatment (Latvia, Archangelsk), reconstruct wards for MDR-TB patients (Archangelsk) and strengthen tuberculosis laboratories (St. Petersburg). Several projects are being implemented in the prison sector. In Latvia and Estonia, Task Force projects have improved tuberculosis control in prisons. In Murmansk, St. Petersburg and Archangelsk, prison projects are contributing to reconstruction work, the procurement of equipment and training.

HIV

The stated objective was to prevent the spread of HIV infection, and reduce incidence to levels prevailing in the other North European states, 20 per 100 000, and, with regard to sexually transmitted infections, STIs, to Central European levels. The outputs were stated to be low-threshold support centres for HIV and STI diagnosis, treatment and prevention, clean needles, syringes and condoms easily available, an increase in awareness and knowl

edge about safer sex and universal access to treatment of pregnant HIV positive women.

The group had an International Technical Adviser, funded by the United States, Sweden and Norway (travel expenses) at its disposal. The group reports that few of the involved experts were accustomed to the Logical Framework Approach, and that because it took time before the website became functional, the tool was not used to its full potential. This issue was in part solved by inviting the International Technical Adviser to play an active role in project formulation. The report further mentions that «the rather decentralized and informal structure of contact between the group and projects, when the main idea is to give the project participants a real (sense of) ownership of their projects, leads to problems of follow up and monitoring of some projects.»

The group also reports that «we are facing a process that is growing and gradually increasing in impact. [The group] has created several international networks at different levels, starting from high-level decision-makers... to the experts at grassroots’ level. This has helped several institutions and projects, which had never before thought about being included in the international network and professional community. This soul of changes and co-operation needs to be kept.»

The group met ten times, latterly in March 2004. The group approved 43 projects, 35 of which received funding. Of these, 25 are under implementation and 10 finalized. The group conducted three peer reviews. At a regional level, several meetings and workshops were organised for medical professionals and other workers in low threshold counselling sites for injecting drug users (IDUs).

The Programme Group on HIV wishes to make two final points:

1. Antiretroviral treatment should be made available to all those infected with HIV.

2. The members of the Programme Group are expressing their willingness to continue their voluntary input provided the conditions make meaningful work feasible.

The largest ongoing HIV/STI project, in terms of funding, is in progress in Lithuania (380 000 €in external funds). It aims to improve the prevention and control of STIs by supporting centres for STI diagnosis and prevention, producing educational materials, organising STI management groups and establishing baseline data. A monitoring visit in January 2004 concluded that most of the project activities had been implemented, although preventive activities had yet to be undertaken.

Similar projects were also implemented in Latvia, Estonia and St. Petersburg. A priority area for Task Force activities has been the enhancement and support of low-threshold activities among IDUs and commercial sex workers to prevent the spread of HIV and STIs. The example of successful activities in such projects resulted in the development of the Network of outreach/counselling centres for IDUs in Latvia, established in collaboration with UNDP. In Estonia, Latvia, Lithuania, St. Petersburg and Murmansk, the Task Force has supported harm-reduction programmes for IDUs and/ or commercial sex workers. In Estonia and Lithuania, Task Force projects aim to prevent the spread of HIV/AIDS in the prison sector. A teaching programme in HIV care is being implemented for nurses from Leningrad oblast and St. Petersburg. In the area of STIs, in addition to the project in Lithuania mentioned above, a number of projects support centres for STI diagnosis and prevention (Estonia, St. Petersburg, Leningrad oblast, Archangelsk). In St. Petersburg, a peer support programme for youths is being carried out.

Antimicrobial resistance

The stated immediate objectives for this group were to establish the patterns of antimicrobial resistance in the different countries; to install a set of common standards and definitions for antibiotic resistance; and to put in place hospital infection control procedures and arrangements in all hospitals in the region.

Also this group reports initial difficulty with the LFA. «Although it was thought that all project participants should be able to use the database as a means of project progress tool, it was the ITA who entered most of the data of the projects into the database. This was done during… the year 2001 and continued in 2002. Later, some of the project leaders hesitantly learned their way through the database jungle and did work with the database, i.e. writing additions to the projects etc.»

The Programme Group established a set of project planning and management guidelines:

1. Relevance – proposals shall be relevant to antibiotic surveillance, antibiotic consumption and hospital infection control.

2. Project leader – the proposal shall designate a relevant contact person to head the project.

3. Established network – the project shall preferably be based upon an established network within the country or the region.

4. Sustainability – the programme shall be sustainable after the project period.

5. Political commitment – the project shall be supported by the governments of the countries involved.

6. Budget – the proposal shall contain a detailed and relevant budget for the project period.

7. Globalisation – the project shall generate results of relevance to sectors other than that within which the project takes place.

It was agreed that the Programme Group should function as a project review committee and in conjunction approve projects according to the above principles.

On a positive note, the report concludes that «The collaboration among programme groups was founded on the ability of the secretariat to keep the information level high, and on the collaboration among ITAs, which appeared to function very well. In this respect, the quality of the Task Force website was extremely high. Also, the input and string pulling of the secretaries from the Secretariat was excellent.» The group also suggests that a longer preparatory phase with time to acclimatize to the whole Task Force concept for the participants of the programme groups would have been advisable. The group had an International Technical Adviser, funded by Denmark, at its disposal. The group met eleven times, the last in March 2004. It approved 25 projects, 21 of which received funding. All of these latter projects are under implementation. The group conducted no peer reviews.

The establishment and strengthening of surveillance systems of antimicrobial resistance was one of the key purposes of the Task Force projects. Laboratory capacity has been enhanced in Archangelsk, Latvia and Lithuania. On a regional level, laboratory staff have received training and a project for the establishment of a template for education in infection control, consisting of material for distance learning, a format for workshops and postgraduate courses, has been set up. Further training workshops were organised in Latvia, Lithuania and St. Petersburg. There have also been regional workshops on standardising methods of testing for antimicrobial resistance. Task Force projects on antimicrobial resistance laid the groundwork and formed an incentive to develop a National Antibiotic Resistance Control Programme in Latvia. The Programme is based on the EU principles in this area. Two hospitals in Estonia received Task Force support for reconstruction and infection control equipment. A major constraint in assessing the effectiveness of these activities is the lack of baseline data. Consequently, several prevalence studies have been initiated, inter alia in Estonia, Lithuania, Murmansk and Poland. However, so far no such information has been posted on the website of the Task Force project database. It will be necessary to wait for these data in order to evaluate progress in reducing the number of hospital-acquired infections.

Evaluation

The Task Force was evaluated under the oversight of a Steering Committee, with members from the London School of Hygiene and Tropical Medicine, Moscow Medical Academy (Sechenov) and Fridtjof Nansen Institute in Oslo. The evaluation team looked at three areas, the political context, the programmes and selected projects. The use of the database, and the monitoring of the database was a forth element.

There are five evaluation reports available. One of the studies, Health as International Politics by Geir Hønnesland and Lars Rowe of the Fridtjof Nansen Institute, was recently published by Ashgate Publishing Ltd. Two complementing programme evaluation reports, from London School of Hygiene and Tropical Medicine, and the Russian Central Research Institute for Public Health Research, and a report on monitoring, including a database user survey from the University of Oslo, are available at the homepage. There are also reports from five of the Programme Groups and peer reviews. A fifth, summarizing evaluation report, issued by the Fridtjof Nansen Institute in Oslo, is forwarded by the Steering Committee to the Summit.

Epilogue

The available information on the burden of communicable diseases in the Eastern part of the Baltic Sea region strongly suggests that more needs to be done to contain these epidemics. Although the rates of new cases may now be falling, the number of people living with HIV/AIDS continues to rise. The registered rates of new tuberculosis cases have stagnated, but are still unacceptably high.

A wide and well-functioning network has been established, at the political as well as the practical and professional levels. These networks must be maintained, and preferably widened. However, future collaboration will probably require less project support and funding, as the economic indicators improve. Technical collaboration, common understanding and mutually supportive strategies, and acting through established networks, will probably be core elements of future collaboration on communicable disease control in the region.