DOTS coverage has increased rapidly in Pakistan since 2000, reaching 63% in 2003. With plans to include the remaining districts, nationwide DOTS coverage should be achieved in 2005. Pakistan has been highly successful in mobilizing financial support for TB control from the international community, and this has given impetus to the programme. The NTP is well structured and has created a strong TB control network during the past five years, with an effective mechanism for coordinating a range of activities and partnerships. Both case detection and treatment outcomes are improving, but remain below the global targets at 17% and 77% respectively. Recent health sector reforms give increased responsibility to the districts for setting priorities for health programmes and to the NTP for ensuring that TB control is a priority at district level. As the programme advances towards nationwide DOTS coverage, the NTP will have to respond to the increasing demand for anti-TB drugs, equipment and reagents, and to ensure that the quality of the services continues to improve.
System of TB control
The NTP is responsible, under the MoH, for the overall coordination of TB control in the country. The specific responsibilities of the NTP include formulation of policy, strategic planning, technical support and supervision, monitoring and evaluation, coordination and communication with partners and research. The provincial and regional TB control managers are responsible for planning, implementing, monitoring and evaluating TB control activities in each province and region. However, districts serve as the main administrative units for the programme; the district authorities are primarily responsible for activities at that level. District hospitals and rural health centres provide diagnostic and treatment services; the basic health units and dispensaries provide treatment. In rural areas, “lady health workers” play an important role in referring TB suspects from communities and in providing DOT. In some big cities, treatment is not yet provided in all health centres.
Pakistan has one national, four provincial and two regional reference laboratories. The national laboratory and three of the provincial labo-ratories have facilities for culture and drug susceptibility testing. In the districts, 619 diagnostic centres do microscopy.
Surveillance and monitoring
No national survey of TB infection or disease has been carried out in Pakistan, and case notifications were erratic until the introduction of DOTS in the early 1990s. The incidence of TB and its trend are uncertain. DOTS coverage increased rapidly from 9% in 2000 to 63% by 2003. During the same period, the smear-positive case detection rate increased from 3% to 17%. While these two indicators have increased, their ratio has not changed, suggesting that the case detection rate within DOTS areas has stayed in the range 20–30% since 2000. A possible reason for the low rate of case detection is that only 30% of all notified TB cases were diagnosed as smear-positive in 2003. Since it is expected that about 45% of incident cases would be smear-positive, the low proportion of reported smear- positives suggests that some smear-positive cases may have been notified as smear-negative.
The treatment success rate in the 2002 cohort was 77%, similar to that in 2001; the default rate remained high at 14%. Furthermore, 13% of treated patients, who were counted as successfully treated, completed treatment without evidence of smear conversion. Information on treatment success outside the DOTS programme is not available. Among relapse cases treated under DOTS, the treatment success was high (81%), but the proportion of patients whose cure was not laboratory confirmed was even higher than among new patients (53%). Among patients who had defaulted on previous treatment, treatment success was only 58%, mostly as a result of patients defaulting again (22% of the cohort).
Improving programme performance
Under the recent health reforms, district governments were authorized to prioritize their district health needs. The NTP needs to ensure that districts take ownership of their local TB control effort and make it a priority. The new National TB Control Programme Plan for 2006–2010 and Provincial TB Control Programme Strategic Plans for each of the four provinces for the same period have been drafted. These will be used to advocate for TB control at the national, provincial and district levels. The induction of national programme officers through USAID funding has helped to develop provincial and district capacity for monitoring and supervision.
The Government of Pakistan is committed to TB control under the DOTS strategy, and the programme is receiving adequate attention from policy-makers, as evidenced by the rapid expansion of DOTS since 2000. DOTS coverage will be expanded to the remaining 20 districts in 2005. With the rapid expansion of DOTS, the NTP faces constraints including inadequate public sector resources. As coverage is increased, the new national plan will progressively focus on the quality of care, enhanced case detection, monitoring and supervision and activities to de-stigmatize the disease. The Pakistan Stop TB Partnership is being launched and has appointed a Stop TB Ambassador. This is the first initiative in Pakistan to include non-traditional partners in TB control activities.
In 2002, the NTP received a two-year grant from the GDF, and this was extended to cover 2005. However, the current level of drug procurement will not be sufficient to meet the increasing needs arising from rapid DOTS expansion. As the use of FDCs is being advocated in the four provinces, the NTP has revised the treatment guidelines and has drafted training materials on their use. There are no drug resistance data available for Pakistan, although WHO estimates a prevalence of MDR in new TB patients of 10%. Patients in whom MDR-TB is diagnosed are not treated under the NTP.
The NTP has recognized the importance of behaviour change, communication and community mobilization in achieving countrywide implementation of DOTS, and support from various donors has been sought to develop effective strategies. Television spots, posters, leaflets, videos and other materials have been developed to raise public awareness. These strategies will be launched in 2005, with the aim of spreading public awareness among both health-care providers and the general public. Innovative approaches, coupled with operational research, are being explored to involve non-traditional partners such as politicians, industrialists, local district governments and religious leaders in TB control activities.
Three 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
The NTP plans to establish an intermediate level laboratory network consisting of one reference laboratory in each district in 2004–2005 and to expand the number of hospitals and rural health centres that serve as diagnostic centres. The national and provincial reference laboratories have been strengthened with the procurement of laboratory equipment, materials and vehicles. Supervision and overall support for the provincial laboratories need further strengthening; guidelines need to be developed as well as tools for supervision, appropriate for the country setting. There are currently no systems in place for quality assurance of microscopy services at the district level, and this is a priority in the 2006–2010 national TB control plan. Other needs include training of laboratory staff and improvement in laboratory operating procedures.
The prevalence of HIV in the general population appears to be low, but the lack of adequate epidemiological data precludes an accurate assessment of the HIV situation in Pakistan. A TB/HIV plan and a national TB/HIV coordinating body are both being developed. TB/HIV awareness activities have been undertaken in conjunction with the South Asian Association for Regional Cooperation (SAARC) TB/HIV Awareness Year (2004).
Links with other health-care providers
Pakistan has developed a national strategy for PPM DOTS. Few initiatives have been launched so far, but there is a strong commitment to encourage the active involvement of more health-care providers, including governmental, semigovernmental and the private sector, in DOTS expansion. Funds from the GFATM are being used to expand PPM and BCC (behaviour change and communication) activities. Several FIDELIS projects linking the NTP to other health-care providers are planned, including improving TB case detection by encouraging intersectoral collaboration in three urban areas and strengthening DOTS implementation in four districts of Punjab. NGOs are involved in some districts of each province and territory of the country; these include the Abasseen Foundation, Aga Khan Foundation, Asia Foundation, Association for Social Development, Marie Adelaide Leprosy Center, Mercy Corps International, Pakistan Anti-TB Association and many other local NGOs.
Partnerships for TB control in Pakistan have been strengthened, and technical and financial support has increased significantly. The NTP has launched the National Pakistan Stop TB Partnership to increase TB awareness and the political commitment of local authorities. Major technical partners include GLRA, GTZ, IUATLD, JICA and WHO. DFID has offered assistance to develop PPM partnerships; USAID has provided support to strengthen the capacity for DOTS implementation in the districts. The governments of Canada, Germany and Japan are the main financial partners for TB control activities. Pakistan will receive ISAC initiative funding (through CIDA) for DOTS expansion and sustainability through the involvement of district governments.
Budgets and expenditures
The budgets for both 2004 and 2005 are substantially higher than in previous years, at about US$ 20 million compared with US$ 5–6 million in 2002 and 2003 (US$ 153 per patient in 2005 compared with around US$ 100 in both 2002 and 2003). These budgetary increases reflect the development of more ambitious plans to accelerate DOTS expansion (to achieve 100% coverage by 2005) and to increase case detection and cure rates throughout the country, and the associated revision of existing national and provincial strategic plans and budgets in 2004 (most of the budgetary increase between 2003 and 2004 is in the category “initiatives to increase case detection and cure rates”). The revised plans include PPM-DOTS strategies and community mobilization activities.
While the funding available for 2004 and 2005 is similar to that in 2002 and 2003, the considerably increased budgets for 2004 and 2005 mean that large funding gaps currently exist: US$ 16 million in the fiscal year 2004 and US$ 8.6 million in 2005 (the fiscal year starts in July). The NTP is already engaged in efforts to mobilize funds to fill these gaps. For example, it is expected that PPM-DOTS strategies will be funded through the national health and population facility (this is supported by the Pakistani government and DFID), and a further application to the GFATM is planned. In addition, provinces are revising their budgetary allocations in the context of the revised strategic plans. Some positive results are already apparent: in December 2004, the Punjab government approved a revised three-year budget allocation of US$ 8.6 million for TB control activities in the province, including US$ 2.4 million for the first year (of which US$ 1.3 million is for drugs).
If the revised NTP budget is fully funded, the total cost of TB control (including health clinic visits for observation of treatment and monitoring and limited hospitalization as well as NTP budget items) will increase from around US$ 5 million in 2002 to US$ 26 million in 2005 (and from around US$ 100 to US$ 213 per patient treated). It remains to be seen whether increased funding can be absorbed effectively and whether increased expenditures result in improved case detection and cure rates.