Ethics and human rights

Applicable regulations regulating ethic principles of a patient and medical staff rights now do not fully comply with the international recommendations.
In particular, patient’s autonomy in choice of treatment options is infringed. For example, in cases of MRD-TB there are two approaches to prescription criteria of treatment regimens: pursuant to the national protocol and pursuant to the order on arrangement of patient’s treatment supported with the Global Fund grant. If a patient does not comply with the GF criteria (according to the case type), he/she will receive state-financed therapy which regimen has lower economic efficiency.
There is also a violation of mutuality – healthcare professionals deserve to receive TB risk payments (60% extra payment basic salary for health hazard), however members of the public, volunteers, community nurses of the Red Cross Society etc. who take part in social support in case of falling ill with TB during a contact with a patient are not entitled for such payments in accordance with the applicable regulations. Some projects provide for breathing masks that minimize the risk of infection. However, such employees deserve for compensation in case of falling ill with TB.
The condition of effectiveness is not fully fulfilled – the new unified clinical protocol was developed based on evidentiary medicine, however the focus is made on the compliance with clinical efficacy without due consideration of the economic aspect. For example, in cases when resistance profile is not known (for a term of 2 months), it is economically more advantageous to start treatment with more expensive and more effective treatment regimen, as not only the cost of medication should be accounted but the cost of a patient’s stay in a hospital as well (which includes not only material costs but also psychological challenge for a patient to be apart from his/her usual social environment for a long time). Another example: according with WHO recommendations, for diagnosis with molecular DNA tests, there should be developed extended criteria regarding the patients who must undergo such tests; however, such criteria in the applicable unified clinical protocol are essentially restricted (article 71). For example, molecular DNA tests are prescribed in all cases of positive sputum smear microscopy, and in case of negative result – only HIV-positive, children (0-17), contacts of MDR-TB and patients with precedent therapeutic failure, excluding any cases of extrapulmonary tuberculosis and the rest of newly identified TB cases with negative sputum smear bacterioscopy. At the same time, there is no well-arranged systemic process in Ukraine to encourage a community to take part in making decisions regarding the TB problem. This could help both with lobbying amendments to legislation and with intensification of community support of patients requiring help with socialization. Conditions of transparency and accountability are fulfilled; all draft regulations are proposed for public discussion. State Service of Ukraine for HIV/AIDS and Other Socially Dangerous Diseases and state institution “Ukrainian Centre for Socially Dangerous Disease Control of the Ministry of Health of Ukraine” post statistical information and reports on implementation of the National Tuberculosis Program on their web-sites.

The applicable Law of Ukraine “On Fighting Tuberculosis” specifies that medical aid must be provided to all patients with TB without any exception, in particular to incarcerated, convicted for restraint or imprisonment, foreigners and stateless persons (articles 18-19). Moreover, it stipulates that the patients have a right for free medical care, information from a healthcare professional, free treatment at a health resort, psychological help, for communication with the family and other persons, for religious ceremonies (article 20).
However, this law features a number of deficiencies, in particular in section 5, article 21 it. 2 reads: “Any owner or a body of company, institution, organization of any corporate form authorized by such owner is not entitled to dismiss an employee due to his/her falling ill with tuberculosis, except for the cases when tuberculosis is a contraindication for occupational work specified in the list of professions, productions and organizations, which employees must undergo mandatory preventive medical check-ups, and his/her transfer to any other job subject to his/her consent is impossible. The list of such contraindications is determined by the central body of the executive power which ensures development and implementation of state policy in the sphere of public health”. This is confirmed with the Order of the Ministry of Health of Ukraine dated 23.07.2002 No. 280: “Contraindication for working in professions mentioned in the List is presence of such diseases and/or bacteria carrying: ... – contagious and destructive forms of lung tuberculosis; - extrapulmonary tuberculosis with fistulas; - lupus of face and arms; ...”. The factor of bacteria carrying may not be applied to TB patients as a contraindication for working in any profession, as even the infected persons with no signs of active TB are bacteria carriers.
Moreover, such unclearly formulated provisions concerning TB patients enables for ambiguous interpretation of their content (for example, contraindication to working in certain professions is presence of contagious and destructive form of lung TB. This item may be interpreted in the following way: only contagious, only destructive, contagious + destructive. Such provision contradicts human rights, as upon completion of treatment/having cured (if destruction is present, without bacterioexcretion) a patient bears no hazard to the environment and may hold any position which he/she could take before the disease.
There is a necessity to revise such contradictory provisions of the Law of Ukraine on fighting tuberculosis and the Order of the Ministry of Health of Ukraine dated 23.07.2002 No. 280 in order to determine clear criteria for contraindications to working in certain professions in specifically identified cases of TB, which would be in line with the international recommendations.