Bangladesh adopted the DOTS strategy in 1993. Since then, the NTP has expanded to cover nearly all of the country. For many years, NGOs have been largely responsible for delivering DOTS services and have had a formal involvement in the NTP since 1994. Their collaboration has been instrumental in promoting DOTS and achieving high DOTS coverage. Participation of NGOs in programme delivery continues to be an enormous asset, while the government ensures coordination and sustainability of TB control. With TB control a government priority, recognized as an essential service to be delivered by the health system, the NTP needs to build capacity and strengthen programme management. This is now a matter of urgency as there has been a large increase in funding, mainly from the GFATM, and the amount of money available for TB control almost tripled in 2004 and 2005. Thanks to this encouraging financial position, ambitious plans have been made to dramatically increase case detection and to accelerate a comprehensive programme to strengthen laboratories. With many and diverse partners from the public and private sectors, clear central leadership will be crucial to ensure coordination, to maintain momentum and to undertake the expanded activities now made possible through the additional funding.
System of TB control
The NTP is recognized as a priority in the revised Health, Nutrition and Population Sector Programme. Under the guidance of the Director-General of Health Services, the NTP manager is responsible for the NTP at central level. At the subnational level, the NTP is integrated into the divisional, district and upazila (subdistrict) general health services. Chest disease clinics, located in district capitals and metropolitan cities, support the NTP by offering diagnostic and treatment services for surrounding areas and serving as referral centres for entire districts. NGOs provide NTP services at upazila level in collaboration with the government; some have their own health-care infrastructure. At the peripheral level, health inspectors and assistants, medical assistants, village doctors and NGO community health workers provide basic services such as identification and referral of TB suspects, provision of DOT, tracing of defaulters and various behaviour-change communication activities.
The NTP has established a network of nearly 600 sputum microscopy centres, each one covering a population of about 230 000, on average. There is one NRL, which is part of the central public health laboratory, and 45 intermediary laboratories in chest disease clinics. Peripheral laboratories are found in upazila health complexes, in private urban facilities, medical colleges and in health services for special population groups including health services in prisons, the police and industry.
Surveillance and monitoring
The incidence rate of TB in Bangladesh is uncertain because the estimate is based on a 40-year-old tuberculin survey and on local prevalence surveys that may not be nationally representative. Between 1980, when WHO records began, and the introduction of DOTS in 1993, the case notification rate appeared to be in slow decline, despite some variation. Since 1994, there has been a significant rise in the average age of TB patients, allowing for demographic changes, and the notification rates for men are higher in older age groups. Together, these observations suggest that the TB incidence rate is falling, and this assumption underpins the projected year-on-year changes in the estimated smear-positive incidence rate for Bangladesh.
The smear-positive case detection rate increased rapidly after the introduction of DOTS, stabilized between 1998 and 2001 at around 23%, but has recently increased again, reaching 33% in 2003. Most of these gains have been made as the role of upazila health complexes in case-finding has increased, in addition to chest disease clinics, which were the dominant source of patients in 1995. Since 2000, the DOTS programme has also reported more patients from metropolitan areas. Despite these improvements, and notwithstanding uncertainty concerning the true incidence rate, case detection by the DOTS programme is still low. Treatment success was 84% for the 2002 cohort and has been 80% or more since 1998. Default (7%) was the most important reason why treatment success was still below the 85% target in 2002. Stimulated by the need to make a better assessment of the scale of the TB problem, and to provide a baseline for evaluating the epidemiological impact of DOTS, the NTP has drawn up plans to carry out a national disease prevalence survey.
Improving programme performance
In 2002, DOTS was expanded to Dhaka city. In 2003, national guidelines were updated to strengthen the implementation of DOTS, including the control of childhood TB. Laboratory manuals have been revised and distributed throughout the country; specific guidelines for involving private practitioners and delivering DOTS services in workplaces are being developed. In view of proposed DOTS expansion activities funded by the GFATM, there is a need to strengthen capacity at the central level. Additional management capacity and technical assistance are urgently needed if the planned activities are to be implemented on schedule.
Collaboration with NGOs and additional partners in the metropolitan city centres has been expanded. With the increasing number of partners, strong supervision and standardized systems for referral, recording and reporting need to be developed. With different NGOs working in the same area, the supervision, structure and accountability between NGOs, the NTP and the Chief Health Officer in metropolitan city areas also need to be addressed.
A TB control steering committee was established to support, direct and monitor procedures and activities to ensure that NTP and global targets are reached. In late 2003, as noted above, international partners assisted the government in developing a plan for a national prevalence survey in Bangladesh.
Short-course treatment for all TB cases has been further standardized with the introduction of new treatment regimens and FDCs. The new treatment regimens follow WHO recommendations and are more consistent with private sector prescription practices, which may facilitate increased referral of patients. They also simplify drug management at all levels. The difficulties of ensuring drug quality and an uninterrupted drug supply have been alleviated by the successful application for funding by the NTP to the GDF. There is no national policy on the management of MDR-TB, and MDR-TB cases are not treated within the NTP. However, the Damien Foundation Bangladesh (DFB) treats all confirmed MDR-TB cases in the areas it covers. The National Institute of Diseases and Chest Hospitals also treats MDR-TB. Some second-line drugs are produced in the country.
A budget for both DRS and DOTS-Plus will be included in the country’s application to the fifth round of the GFATM. Should the GFATM application be approved, Bangladesh will apply to the GLC for reduced-price quality-assured second-line drugs and for technical assistance in implementing sound MDR-TB control measures.
Three other areas in which programme performance needs to be improved are diagnostic and laboratory services, TB/HIV coordination and links with other health-care providers.
Diagnostic and laboratory services
EQA is becoming a routinely accepted standard in many NGO-supported areas in Bangladesh, and NGOs are offering their services to the government to expand EQA. A major challenge for the NTP is to refocus the NRL on training, EQA, expansion of culture services and drug susceptibility testing, in addition to routine microscopy work. Future laboratory priorities include basic training for newly appointed technicians and refresher training for all laboratory staff on smear microscopy and quality assurance. Diagnostic services will be expanded by establishing new microscopy centres in upazilas with population coverage greater than 300 000. By 2005, EQA for smear microscopy should be available in all urban and rural diagnostic centres.
The HIV prevalence in the adult population (aged 15–49 years) and the proportion of HIV-positive patients among adult TB cases are still low at 0.01% and 0.1%, respectively, according to the latest UNAIDS and WHO estimates. A similar figure for HIV prevalence among TB cases was found in Dhaka in 1999. There is as yet little collaboration between the NTP and the national HIV/AIDS programme.
Links with other health-care providers
Most DOTS implementation in Bangladesh has been done by NGOs, and during 2004 their involvement has increased. The main NGO partners include the Bangladesh Rural Advancement Committee (BRAC) and DFB, who together cover most of the rural districts in the country; urban areas are covered mainly by other NGOs. There are a number of PPM-DOTS initiatives in Bangladesh. Several private chest physicians in Dhaka have become involved in DOTS services, and the participation of more private practitioners is needed. DFB is expanding its cadre of private “village doctors”, who are currently responsible for the detection of about 10% of patients and the provision of DOT to 45% of patients in DFB areas. BRAC has started similar initiatives in periurban areas, while in rural areas they deliver DOT through a network of community workers. Recently, the NTP and collaborating NGOs have begun to include medical colleges, prison health services and the private corporate sector in DOTS activities.
Several technical partners participate in TB control activities in Bangladesh, led by BRAC and the DFB. Thanks to the joint efforts of the partners, the CCM has made a successful application for funding from the GFATM. Financial support is also provided by CIDA, the World Bank and other partners through general funding for the health sector.
Budgets and expenditures
The TB control budget data reported to WHO include both a budget for the NTP and the budgets for the two major NGOs that are responsible for DOTS implementation in most of Bangladesh (i.e. BRAC and DFB). The budgets for both 2004 and 2005 are substantially higher than in previous years, at about US$ 20 million compared with US$ 7 million in 2003. This reflects an ambitious plan to more than double the number of patients treated between 2003 and 2005. Most of the budget is funded for both 2004 and 2005, mainly because of increased funding from a World Bank credit and a substantial GFATM grant. There is a funding gap of US$ 1–2 million in both 2004 and 2005; this money is needed to cover the national prevalence survey, to recruit staff in order to strengthen management at the central level and to carry out additional activities to increase case detection and treatment success rates. The substantially improved funding position means that spending on TB control by the NTP and the major NGOs could almost triple between 2003 and 2005. The larger budgets in 2004 and 2005 will allow for increased spending on first-line drugs, in line with projected increases in the number of patients treated as well as the development of a buffer stock in 2005 (this buffer stock is the reason for the relatively high budget for first-line drugs in 2005). They will also allow for some investment in infrastructure, and increased spending on initiatives aimed at improving case detection. The NTP budget per patient is projected to increase from US$ 80 in 2003 to US$ 116 in 2005; if this happens, the total cost of TB control, including visits to health clinics for observation of treatment and monitoring, and limited hospitalization, is projected to increase from US$ 10 million in 2003 to US$ 27 million in 2005 (from US$ 115 to US$ 146 per patient treated). It remains to be seen whether the increased funding can be absorbed effectively and whether increased expenditures result in improved case detection.