Results: Planning and DOTS implementation
Constraints and remedial actions
The country profiles in Annex 1 (objective 2) incorporate information from the summary planning tables (objective 1) that were prepared for the 2003 DEWG meeting. Thirteen major constraints to reaching the targets for case detection and treatment success were identified in the 22 HBCs (Table 13 ). Although TB control efforts in many countries are hampered by nearly all of these constraints, the table focuses on the principal obstacles in each country.
The 6 constraints most commonly identified were: lack of qualified staff; poor monitoring and evaluation; inadequate infrastructure; weak laboratories; insufficient engagement in DOTS of private practitioners and other health providers; and limited commitment to, and capacity for, implementing DOTS in peripheral health services:
1. Lack of qualified staff. As in 2003, the lack of qualified staff is considered to be the largest barrier to reaching the targets for case detection and cure. China, DR Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, South Africa, Tanzania, Uganda, and Zimbabwe report major deficiencies in staff at central level. Following decentralization, there has been inadequate planning for, and provision of, the technical support that would enable staff at provincial and district levels to successfully assume the new responsibilities assigned to them. Afghanistan, Bangladesh, Cambodia, Kenya, Mozambique, Myanmar, and Pakistan have staff with inadequate qualifications working at the peripheral level.
2. Poor monitoring and evaluation. Recording and reporting remain weak in Afghanistan, Bangladesh, Brazil, China, DR Congo, Ethiopia, Indonesia, Nigeria, the Philippines, South Africa, Russian Federation, Thailand, and Zimbabwe. Timely and reliable data are essential for planning corrective actions and for monitoring trends.
3. Inadequate infrastructure. Lack of transportation infrastructure in the form of roads and vehicles, poor communication networks, unreliable or non-existent electricity supplies, inadequate buildings and equipment, and weak primary health care systems all impede NTP efforts to control TB. The following countries suffer deficiencies in at least one of these areas: Afghanistan, China, DR Congo, Ethiopia, Kenya, Myanmar, Mozambique, Nigeria, Pakistan, Tanzania, Uganda, and Zimbabwe.
4. Weak laboratories. Progress in Afghanistan, DR Congo, Ethiopia, Mozambique, Myanmar, Nigeria, Pakistan, South Africa, Tanzania, and Uganda is constrained by poor laboratory quality control, the lack of a laboratory network, or limited access to laboratory services. Among possible solutions are systematic implementation of EQA organized by reference laboratories, and involving laboratories that are currently used for other purposes in TB control. Myanmar plans to buy diagnostic equipment with funds from the GFATM.
5. Poor involvement in DOTS of private or non-NTP public providers. Many countries fail to make best use of existing health system capacity by not involving all clinicians and facilities, both public and private, in providing DOTS services. Inadequate partnership in TB control between the NTP and other bodies and institutions is a major obstacle to success in Afghanistan, Bangladesh, Cambodia, India (with exceptions), Indonesia, Kenya, Pakistan, the Philippines (with exceptions), Tanzania, and Viet Nam. PPM projects (e.g. India, the Philippines) seek to involve private practitioners in DOTS delivery, with the goals of standardizing care and improving the reporting and monitoring of patients. Other projects are working to involve non-participating public health facilities, such as hospitals in major cities.
6. Limited commitment to, and capacity for, implementing DOTS in peripheral health services. Decentralization aims to improve access to primary care, and to DOTS. Although decentralization has been under way for years in many countries, it continues to be a major constraint to TB control because of the lack of capacity at the periphery to handle what were previously central level responsibilities. Bangladesh, Brazil, Ethiopia, Indonesia, Mozambique, Nigeria, Pakistan, South Africa, and Thailand are still working to develop peripheral health system infrastructure and capacity, to obtain local political commitment, and to ensure the proper distribution of funding for TB control programmes. Countries with systems that were recently decentralized, such as the Philippines, are still finding it hard to expand and strengthen DOTS because they lack local political support. Possible solutions include the strengthening of central and provincial teams, and the provision of technical support to local health authorities.
Seven further constraints have been identified. They are, in brief:
7. Wavering political commitment. Weak and unstable political commitment, either centrally or peripherally, continues to obstruct TB control efforts in several countries. China still faces a lack of political commitment in some provinces and counties, and DR Congo, Ethiopia, Mozambique, Nigeria, South Africa, Thailand, and Zimbabwe reported limited commitment to TB control from central and peripheral levels. Remedial actions include providing better support to local government following decentralization, forming provincial task forces, expanding international support through high-level advocacy missions, and country-level advocacy for TB control in civil society, especially in support of patients infected with HIV.
8. Increasing TB/HIV co-infection. As in 2002, HIV was thought to be one of the main constraints to TB control in Cambodia, Kenya, South Africa, and Uganda. Three more countries joined that list in 2003: Mozambique, Tanzania, and Zimbabwe. NTPs are developing plans to collaborate more effectively with HIV/AIDS programmes. Although there are other countries with high rates of HIV infection, they have more pressing constraints that must be attended to first.
9. Limited access to DOTS. In Afghanistan, Cambodia, China, Nigeria, the Russian Federation, and Zimbabwe, some of the population has no or poor access to DOTS due to poor infrastructure, weak DOTS expansion, or lack of integration of DOTS into the primary health care system.
10. Low public awareness. Limited knowledge about TB and its treatment, and the stigma of having TB (and perhaps also HIV infection), both hamper efforts to detect and treat TB suspects in Afghanistan, Cambodia, India, Myanmar, Pakistan, and the Philippines. The implementation of effective and adequately funded COMBI plans could help to overcome this obstacle, but only India among these countries currently has such a plan.
11. Administrative constraints and adverse policy. Afghanistan, Bangladesh, Ethiopia, India, Nigeria, and the Russian Federation suffer from administrative constraints, or have policies inconsistent with the implementation of DOTS.
12. Unreliable drug supply or undeveloped drug policy. Nearly all HBCs had a secure supply of anti-TB drugs in 2003, thanks in large part to the GDF. The Russian Federation continues to have difficulties in controlling drug quality, Bangladesh does not have assured supply and distribution of drugs, DR Congo has problems with distribution of standard drugs throughout the country, and Viet Nam still lacks an effective drug policy.
13. Insufficient funds. A lack of money is no longer one of the top constraints identified by the majority of HBCs. However, there are 2 different reasons for this. On the one hand, governments (especially of richer countries) make large contributions to TB control, donors have increased their investments, and the GFATM began to disburse money in 2003. As a result, some NTPs genuinely have enough money. On the other hand, some NTPs perceive no shortfalls in funding because their budgets are incomplete, or because their plans for TB control are not sufficiently ambitious (see Financing DOTS expansion below). Eleven of the HBCs reported some level of funding gap in their 2003 budgets. Some of these countries report problems in distributing funds from local or central governments to programmes (e.g. Nigeria, the Russian Federation).
Partnerships and coordination
Although coordination of partners' activities has been steadily improving through discussion within and among 3 working groups of the Stop TB Partnership (DOTS expansion, TB-HIV, and MDR-TB), there is still need for better coordination of country activities to reduce duplication of efforts. WHO and the Stop TB Partnership are working to identify overlaps, and to ensure better internal coordination of country activities. All regions organize coordination among regional partners, to greater and lesser degrees, using mechanisms such as regional ICCs, task forces, and meetings of interested parties. NICCs have now been meeting regularly in all HBCs except Mozambique and South Africa. In countries applying to the GFATM, a well-established NICC serves as a model for organizing the Country Coordination Mechanism required by the Fund. In some countries, the NICC for TB remains a sub-committee of the CCM.
Planning for MDR-TB control
Since publication of the 2nd WHO/IUATLD report23 on anti-TB drug resistance in the world, new data on the prevalence of MDR-TB have been collected in 7 HBCs, or from parts of these countries, including 3 that were previously surveyed between 1996 and 1999. Surveys were repeated in Thailand, China (Henan province), and in the Russian Federation (Tomsk oblast). Drug resistance data have been reported for the first time by Cambodia, China (Hubei and Liaoning provinces), South Africa (national survey), DR Congo (Kinshasa), the Russian Federation (Orel oblast), and India (North Arcot, Raichur, and Wardha districts). There are no data on MDR-TB rates for Afghanistan, Bangladesh, Ethiopia, Indonesia, Nigeria, Pakistan, the Philippines, and Tanzania. The new data, where available at the time of writing, are summarized in the text of country profiles at Annex 1, along with estimates for other countries (in data tables). The results of the new surveys will be described in full in the 3rd WHO/IUATLD report, to be published in 2004.6
The DOTS-Plus initiative develops global policy on the management of MDR-TB and facilitates access to second-line drugs. As part of this process, and under the continuous monitoring of the GLC, several DOTS-Plus pilot projects have been established to evaluate the feasibility and cost-effectiveness of using second-line drugs for managing MDR-TB in countries with limited resources. Projects approved by the GLC have access to quality-assured, second-line drugs at concessionary prices and benefit from technical support and monitoring. The Philippines and the Russian Federation have DOTS-Plus pilot projects approved by the GLC. India and Kenya have DOTS-Plus applications to the GLC under review, and Tanzania and Viet Nam are planning to apply.
The results of planning activities related to MDR-TB are reported in the individual country profiles for China, India, Kenya, Nigeria, the Russian Federation, South Africa, the Philippines, and Viet Nam.
Collaborative TB/HIV activities
Collaborative TB/HIV activities in the 22 HBCs are detailed in each country profile in Annex 1, and summarized in Table 14 . No country has yet implemented any collaborative activities on a national scale. However, 15 of the HBCs have TB/HIV coordinating bodies, and 12 carry out small-scale, joint TB/HIV planning activities. Three of the countries that have listed HIV as a constraint (Tanzania, Uganda, Zimbabwe) do not yet have a TB/HIV coordinating body, which makes planning more difficult. The majority of the HBCs neither routinely test TB patients for HIV, nor actively look for TB among people infected with HIV, and most do not have national surveillance systems for assessing the scale of the TB/HIV problem. The twin goals of testing TB patients for HIV infection, and testing HIV-infected persons for TB, have been achieved in Brazil, Cambodia, China, India, Indonesia, Myanmar, the Russian Federation, and South Africa, but only on a limited scale in each country. Most of the HBCs do not yet monitor and evaluate collaborative TB/HIV activities, do not offer isoniazid preventive therapy, and do not routinely provide TB patients with the means to prevent HIV infection. The majority of HBCs do not provide ART, or offer little additional care and support for TB patients infected with HIV.