Afghanistan has undertaken a programme of health service reconstruction. With help from international partners, funds have been mobilized to create an NTP and to start DOTS activities. The DOTS strategy is included in the country’s basic package of health-care services (BPHS). Afghanistan has brought together many NGOs in a common effort to deliver DOTS services, and their involvement has been critical in carrying out programme activities. Along with the general health system, TB control services face several impediments, notably an inadequate number of health facilities, continuing insecurity in many areas and staff shortages at all levels. Nevertheless, the NTP has made substantial progress in recent years. DOTS coverage has increased slowly and treatment success rates have been close to or above the global target for four consecutive years. Improving the currently low case detection rate will require improvements in the security situation. In Afghanistan, more women than men seek treatment from the public TB control programme; it is possible that more men than women are treated by private practitioners. Private physicians and other health-care providers including community volunteers are being encouraged to engage in DOTS.
System of TB control
Over the past two decades, the health service infrastructure collapsed; reconstruction is hampered by the dangers of working in regions where the central government is not fully in control. Nevertheless, progress has been made in rebuilding the general health system, including TB services. The DOTS strategy is a component of the BPHS, and since 2002 the NTP has been strengthened at all levels.
The NTP consists of a central unit under the MoPH General Directorate of Health Care and Promotion, which is responsible for the overall implementation and management of the NTP, and for policy development. The National TB Institute (NTI) at the central level in Kabul supports training, technical assistance, operational research and laboratory activities. In provinces and districts, TB coordinators supervise and monitor DOTS activities in general health service facilities on four levels: health posts, basic health centres, comprehensive health centres and district hospitals.
There is no national reference library (NRL) in Afghanistan, but the NTI is upgrading its activities so that it can function as an NRL. Additionally, there are eight regional and 144 district laboratories for diagnostic activities.
Surveillance and monitoring
Surveillance was improved with the introduction of the DOTS strategy in the late 1990s and, although the 2003 estimate of 53% DOTS coverage is probably optimistic, there was a steady rise in the number of smear-positive cases diagnosed between 1997 and 2002. With these improvements, the estimated case detection rate was 19% in 2002 and 18% in 2003. Although the case detection rate is not expected to be much higher than this, a tuberculin skin-test survey carried out in Kabul in 2000 1 suggests that the national incidence rate of 150 smear-positive cases per 100 000 population could be an overestimate. This is one aspect of case detection that needs further scrutiny in Afghanistan. Another is the unusual finding, noted in Global Tuberculosis Control 2004, that many more women seek treatment from the DOTS programme than men, especially among young adults. Operational research to address this issue is almost complete, and the results will be available in early 2005.
Treatment success among DOTS patients registered in 2002 was 87%, and has exceeded the 85% target in three of the last four annual cohorts. With respect to monitoring progress towards the Millennium Development Goals, the focus in Afghanistan is still on assessing TB burden and trends, and on evaluating DOTS implementation.
Improving programme performance
Given the dangers of working in some provinces, national and international experts are sometimes unable to carry out supervision and monitoring visits. Nevertheless, a network of 46 national TB experts has been established, including an NTP manager, a deputy NTP manager, a National Surveillance Officer, a National Logistics Officer, the NTI director and a deputy, eight regional coordinators and 32 provincial coordinators. National TB guidelines have been revised and translated into the Dari and Pashtu languages.
More than 900 health personnel have been trained to provide DOTS services since early 2002. Once the organization of the NTP is complete, the priorities will be to further develop the HR development strategy and to increase training of staff at all levels. A national workshop on HR development for TB control was conducted by the NTP and WHO in March 2004 to revise the basic curricula for all health personnel through the development of appropriate learning materials and training schedules. Five medical schools are preparing training material and courses for all disciplines and are introducing DOTS into the undergraduate curriculum.
Reconstruction of health services has taken place through contracting NGOs to provide basic health services, including TB control, in geographically defined areas. Contracts have been made with 30 NGOs.
In September 2003, the NTP and WHO, in agreement with other partners, procured anti-TB drugs in bulk through the GDF; this supply should cover the needs for 2004 and part of 2005. To maintain regular supplies to all regions, a national warehouse of anti-TB drugs and laboratory consumables was set up at the NTI, and a computer programme for calculating drug needs and requests has been developed. There are no data on drug resistance, DST is not performed and second-line drugs are not available.
Other areas in which programme performance needs to be improved include diagnostic and laboratory services, links with other health-care providers and links with the community. The need for collaborative TB/HIV activities is unclear, given the lack of information about the prevalence of HIV.
Diagnostic and laboratory services
Diagnostic and laboratory services in Afghanistan face major difficulties because of inadequate laboratory equipment and supplies, limited numbers of trained staff and high staff turnover. In 2004, microscopes, reagents and other laboratory materials, including microscopy slides and sputum containers, were purchased and distributed with support from donors. Once basic infrastructure is developed, the priorities will be training of staff, the establishment of an EQA system, and regular monitoring and supervision.
No data are available on the prevalence of HIV in the general population or in TB patients. A rapid appraisal of the HIV situation is planned, which will provide an estimate of the prevalence of HIV in the general population and among various vulnerable groups.
Links with other health-care providers
The NTP regards the involvement of private sector providers as an important component of DOTS implementation and expansion. Many patients are treated privately, but private physicians are not yet involved in DOTS services. The NTP plans to establish a PPM-DOTS task force and to develop PPM guidelines. Progress in including all relevant public sector providers in DOTS has been made, and public hospitals, medical colleges, prison health-care services and army health facilities are now involved in many areas.
Links with the community
There is community involvement in TB control activities in Kabul City, where around 10 000 widows have been trained to assist with health education. In Nemruz Province, local people help with TB case referral.
An interagency coordination committee (ICC) for TB control has been established and holds regular meetings in Kabul. A country coordination mechanism (CCM) to facilitate support from the GFATM also exists, and meets monthly to address technical and operational issues. WHO and JICA are the main technical partners, and several NGOs including the Anti-TB Association, CARE International, COOPI, GMS, LEPCO, MEDAIR and MSF are providing additional technical assistance. CIDA, the Government of Italy and USAID are the major funding partners.
Budgets and expenditures
Budget and expenditure data are limited for Afghanistan. The NTP budget has been approximately US$ 3–4 million in each year 2003–2005. Almost all funding is provided by grants, including from the GFATM. It is extremely difficult to estimate either the total funds needed or the funding gap because of the highly volatile situation in the country. Although a funding gap of US$ 1.5 million was reported for 2003 (see Global Tuberculosis Control 2004), the general situation has deteriorated and it is likely that in 2004 and 2005 the funding gap is much greater. This is illustrated by the funding gap for the BPHS, which includes TB control. For the years 2004 and 2005, the funding gap for the BPHS is US$ 49 million and US$ 43 million respectively, and is expected to increase to US$ 70 million in 2006.
A breakdown of the NTP budget by line item is not available for any year 2003–2005, although expenditures on drugs were reported to be about US$ 1 million in 2003 (equivalent to about US$ 74 per patient treated), and relatively large investments in infrastructure were made in the same year.
1 Dubuis M et al. A tuberculin skin test survey among Afghan children in Kabul. International Journal of Tuberculosis and Lung Disease 2004, 8:1065–1072.