After a period of rapid DOTS expansion, Myanmar achieved nationwide DOTS coverage by the end of 2003. That year, more than 75 000 TB cases were reported, corresponding to a case detection rate of 73%; more than 80% of the 2002 cohort were treated successfully. With a strong national health infrastructure and government recognition of TB as a top priority, the country is now within sight of becoming the second of the current group of HBCs 5 to reach the global targets for DOTS implementation (after Viet Nam). Myanmar has made these commendable achievements with little external donor support. This situation will change radically with a massive increase in funding, mainly from the GFATM. When they become accessible, these funds will provide major opportunities for capital investment in infrastructure as well as important improvements in staffing at all levels and in the quality of laboratory services. They will also enable sustainability and strengthening of all aspects of the NTP including further boosting of treatment outcomes. Several NGOs now participate in the provision of TB control services, and the NTP is promoting the involvement of other health-care providers, particularly private physicians and clinicians from large hospitals. A national TB prevalence survey would provide a more accurate estimation of incidence and a baseline for assessing the impact of DOTS services on the TB epidemic.
System of TB control
The NTP functions through a central level office and 12 state or divisional TB centres. There is one central drug store and two subnational stores in upper and lower Myanmar. Township hospitals serve as the DOTS treatment units, and TB registers are maintained at this level for the population in each township.
The NRL was established in 2001, and there are two subnational laboratories. Since 2003, all state and divisional laboratories participate in a quality assurance network. Sputum smear microscopy is done in 309 of 324 townships. The NRL carries out drug susceptibility testing and, together with the subnational laboratory in Mandalay, also performs culture.
Surveillance and monitoring
The total number of reported TB cases increased from less than 15 000 in 1998 to more than 75 000 in 2003, with DOTS coverage reported to be 95% of the population during 2003 (rising to 100% towards the end of the year). During the same period, the smear-positive case detection rate increased from 29% to an estimated 73%, exceeding the 70% target. During this period of rapid DOTS expansion, the proportion of all new cases diagnosed as smear-positive fell from 68% (1998) to 36% (2003), which raises questions about the accuracy of the microscopic diagnosis. Treatment success has exceeded 80% since 1997, but moderately high default rates (9% in 2002) have limited the rate of success. As expected, the treatment success rates are somewhat lower for patients undergoing re-treatment (76% among relapses, 75% among all re-treatment cases combined). Nonetheless, on current evidence, Myanmar is close to reaching the targets for case detection and treatment success. One important caveat is that the denominator of the case detection rate – the estimated smear-positive incidence rate – is based on disease prevalence surveys carried out up to 1994. A decade later, a new national prevalence survey would provide a valuable reassessment of the burden of TB in Myanmar, give a baseline against which to evaluate DOTS impact and yield important information about the quality of diagnosis and treatment.
Improving programme performance
Development of human resource capacity has been strengthened, but many challenges still remain. An HR database is in place and shows that approximately a quarter of all sanctioned posts in the NTP are vacant. An HR development plan was prepared with WHO in 2003 and has already resulted in intensified training activities and the appointment of new staff. Future plans include cascade training of staff involved in TB control at all levels, including community volunteers, national NGOs and private physicians. The GFATM will support training activities and HR development; the NTP will apply for additional support through ISAC’s second round of funding.
GFATM funding will also be used to increase monitoring, supervision and evaluation of programme activities and to strengthen DOTS by involving community and national NGOs and private providers, and by improving tracing of defaulters. The role of WHO will be to provide technical support to the principal recipient and subrecipients for planning, implementation and monitoring and evaluation of the TB component of the GFATM grant.
Myanmar currently receives anti-TB drugs through the GDF, which will provide a third year’s supply of drugs for 2005, including a buffer stock. The GDF is considering a second term of three years beyond 2005. Following a successful pilot project to introduce FDC anti-TB drugs in the divisions of Mandalay and Yangon, all State/Divisional TB Officers were trained in FDC anti-TB drug management, and FDCs have been introduced nationwide through cascade training of the Township Medical Officers. A nationwide drug resistance survey was completed in 2003, with the prevalence of MDR-TB among new cases estimated at 4.0%. There is no national policy on MDR-TB management; patients are treated on an individual basis.
Three other areas where 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
Although the TB laboratory infrastructure is improving, strengthening of the national laboratory network is needed, especially the expansion of sputum smear microscopy centres, reinforcement of quality assurance at the township level and upgrading of the subnational laboratory in Mandalay. Another constraint is the shortage of qualified staff, especially junior laboratory technicians, which will be addressed as a priority for 2005. In addition, strengthening techniques for culture and drug susceptibility testing at the NRL in Yangon and the subnational laboratory in Mandalay are planned. It is also planned to introduce culture in four state/divisional laboratories in Bago, Mawlamyine, Pathein and Taunggyi.
The HIV prevalence among TB patients was estimated to be 4.5%, based on surveillance carried out in 20 sentinel sites from 1995–1997. This is lower than the current WHO estimate of 6.8%. No recent estimates from surveys are available, but a new HIV prevalence study among TB patients is planned once funding from the GFATM becomes accessible. Funding from GFATM will also support TB/HIV training for NTP staff at all levels. Political commitment has been demonstrated by the establishment by the MoH of a high-level coordinating body on TB/HIV. TB/HIV prevention and control activities were implemented in five pilot townships in 2000, including VCT for TB patients and provision of HIV education and prevention for HIV- infected TB patients. These activities were discontinued because of lack of funding. Currently, there are limited collaborative TB/HIV activities in the country. Treatment guidelines for TB/HIV have been developed. VCT is available at a small number of VCT centres, at some drug treatment centres and at hospitals offering prevention of mother-to-child transmission programmes.
Although a supply of drugs for ART has arrived in Myanmar, ART is not yet available through the public sector. Some international NGOs such as MSF Holland and MSF Switzerland are providing ART to TB patients on a small scale. A WHO/National AIDS Programme/NTP/IUATLD/Total Exploration and Production Myanmar project will put 200 TB patients on ART in five townships in Mandalay Division in 2005. Partners within the government, and national and international NGOs have expressed interest in working with the NTP to strengthen existing TB/HIV activities and to actively engage in extending TB/HIV activities.
Links with other health-care providers
Involvement of general hospitals has increased rapidly during the past two years. In some areas, TB cases notified from general hospitals represent a substantial proportion of all cases registered under DOTS. However, a high proportion of the cases notified from hospitals are extrapulmonary or sputum smear-negative pulmonary TB, which raises some concern about the diagnostic quality in these hospitals. Involvement of army, police and prison health services has started but is still limited.
The Myanmar NTP has developed national guidelines for involvement of private practitioners in TB control. So far, two initiatives to involve private providers have been launched. In Mandalay Division, the NTP, together with the Department of Medical Research, started a project in 2002 to involve private physicians in diagnosis and treatment under the NTP. In Yangon, an international NGO (Population Services International) started implementing DOTS in 2004 as part of its existing franchising scheme, under which private physicians deliver diagnostic services at low cost and provide treatment with drugs free of charge from the NTP. Both initiatives have contributed substantially to increased case detection in targeted townships. Several additional initiatives are planned, including a training programme for private physicians, which will be coordinated by the Myanmar Medical Association, and a joint initiative by JICA and NTP to involve private practitioners in selected townships in Mandalay and Yangon Divisions.
Many national and a limited number of international NGOs work together on TB control in Myanmar. IUATLD supports operational research, TB/HIV activities including ART, and procurement of cars and laboratory equipment and supplies. WHO provides technical support and assists with HR development and procurement of drugs and laboratory supplies. JICA offers laboratory training, and anti-TB drugs are supplied by the GDF. The GFATM will soon be the main funding partner. The Country Coordination Mechanism has merged its working group with the Technical Working Group on TB hosted by WHO. The role of this working group is to support the United Nations Theme Group on Health (UNTGH) and the GFATM principal recipient, the UNDP, by providing technical advice on all aspects of the implementation of the TB control programme funded by the GFATM and by other external sources, and by coordinating all operational and technical aspects between implementing agencies.
Budgets and expenditures
The NTP budget was around US$ 3 million in 2002, but a large funding gap meant that actual expenditures were only around US$ 1 million, primarily for staff and first-line drugs. The establishment of the GFATM has created new funding opportunities for the NTP, and following a successful GFATM application in 2003 the budget for 2004 was US$ 6.3 million. It was anticipated that the GFATM would provide about US$ 4 million of the required funds. However, because of delays in signing the initial two-year grant agreement, the first disbursement was only received by the GFATM principal recipient in September 2004, and thus a substantial funding gap remained. Provided that GFATM funds can be transferred to subrecipients and further disbursements are made according to the grant agreement, funding for the NTP will dramatically improve in 2005, and the GFATM will be by far the most important source of financing. If this happens, funding per patient treated is likely to rise as well, from expenditures of US$ 20 per patient in 2002 to a budget of US$ 70 per patient in 2005. Since case detection is already high, increased funding will mainly provide for improvements in the quality of the existing infrastructure, which are needed to sustain the achievements that have already been made, and to support further improvements in case detection. Much of the increased budget in 2005 is for capital investments that will benefit patients for many years. Thus budgets for subsequent years will be lower (some of these investments were originally planned for 2004, but needed to be deferred to 2005 because of lack of funds; this explains why the budget developed for 2004 was higher than that for 2005). Costs beyond those reflected in the NTP budget are limited in Myanmar, at about US$ 1 million per year. If the NTP budget is fully funded in 2005, total TB control costs will rise from about US$ 2 million in 2002 and 2003 (about US$ 30 per patient treated) to US$ 6.1 million in 2005 (about US$ 80 per patient treated).
5 Peru was excluded from the original group of HBCs, having met the targets and successfully reduced incidence.