Thailand has had nationwide DOTS coverage since 2002 and reached the global target for case detection in 2003. Recent data suggest that the incidence of TB is declining slowly in Thailand. Considerable efforts are being made to extend TB control services to marginalized and deprived population groups, and this has boosted the case detection rate. However, treatment success is still well below the DOTS target and too many patients die, fail to complete their treatment or are lost to follow-up. In contrast to most HBCs, diagnostic laboratories in Thailand are relatively well equipped and maintained, but the shortage of adequately trained staff is still a problem. The estimated prevalence of HIV in Thailand is higher than in any other country in the WHO South-East Asia Region. A national TB/HIV coordinating body has been set up and is planning joint TB/HIV activities. The recent reform and decentralization of the country’s health sector is changing the responsibilities and funding arrangements for TB control; the full implications of this for TB control are still unclear.
System of TB control
The central office of the NTP has become a cluster within the Bureau of AIDS, TB and STIs, following the recent reorganization of the Department of Disease Control (DDC) of the MoPH. The TB cluster is responsible for the development of technical policies, planning and monitoring of TB control in the country. The procurement and distribution of anti-TB drugs have been decentralized to the provincial and district levels as part of the health- sector reform process. Twelve regional TB centres and the TB cluster in Bangkok are responsible for monitoring, training and supervising of provincial and district-level staff. Health inspectors monitor the provincial hospitals and health offices and have a strong influence on provincial and district health-care programmes. Certain programmes are now given priority and efforts have been made to include TB control among these priority programmes.
Under the health-sector reform project, a number of managerial tasks for the TB control programme, including planning and budgeting for activities such as training and supervision, have been decentralized to the provincial and district levels. District TB Coordinators (DTCs) are responsible for coordinating TB control activities, and work in close collaboration with the TB clinics in the hospitals. One effect of the health-sector reform policies will be to weaken the role of provincial and district health offices, as planning and budgeting authority will now rest with the provincial and district hospitals. In many districts, clinic staff in TB hospitals have assumed some of the responsibilities of the DTCs.
Laboratory diagnostic services in Thailand are provided by one NRL, 167 provincial and 678 district laboratories. All laboratories do smear microscopy, about 85 do mycobacterial culture and eight have facilities for DST. Regional and university laboratories perform culture on request for sputum smear-negative cases.
Surveillance and monitoring
Annual case notifications from 1980 to 1995 suggest that the underlying trend in incidence is downwards, masked since 1998 by improvements in case detection. Notification rates are highest in elderly men and women, which is consistent with a long-term downward trend in TB incidence. However, the recent impact of HIV on TB incidence cannot be determined from the nationally aggregated data. The prevalence of HIV among adult TB cases was estimated to be 8.7% in 2003, but HIV prevalence has been falling for several years, and TB incidence may also still be falling.
According to the most recent estimate, Thailand has exceeded the target for case detection, reaching 72% in 2003, following the rapid increase in DOTS population coverage between 1995 and 2002. In contrast, treatment success was well below target at 74% in the 2002 cohort, mainly because 11% of patients died while on treatment and 13% defaulted or were transferred between treatment centres without subsequent follow-up of treatment outcome. Among patients registered for re-treatment, the success rate was only 62%; 17% of patients died while on treatment. There has been no systematic improvement in treatment success in Thailand since data were first submitted to WHO in 1995. Given the rapid recent increase in DOTS coverage, and the apparently high rate of case detection, Thailand should consider assessing the quality of treatment observation and ensure that reporting and recording are accurate. A recent programme review showed that parts of the database were incomplete and inconsistent.
Improving programme performance
In 2003, Thailand introduced a countrywide health insurance scheme for all clinical services known as the universal coverage (UC) scheme. The budget for this programme covers drugs and supplies for an “essential package of care” delivered at MoPH facilities and other health-care facilities under contract with the MoPH. Since 2002, following health-sector reforms, anti-TB drugs have been financed through the UC scheme. It is intended that training, supervision and monitoring activities for specific disease control programmes be financed through a non-UC budget available through the DDC at the MoPH. The TB cluster at the central level must use non-UC funds for the organization of national training courses, supervision in the regions and the organization of monitoring meetings for regional staff. During 2004, many training and monitoring activities required by NTP policy could not be carried out because of lack of funding at the peripheral level. Although funds are available for supervisory activities in 2004, the funding of training activities and monitoring meetings will require further negotiation with the DDC. The administrative process for the provision of non-UC funds at provincial and district levels is still being developed.
During the expansion of DOTS activities from 1996–2001, initial training was carried out for health-care workers at all levels. However, because of the high turnover of staff and the lack of systematic refresher courses, there is now a shortage of adequately trained TB control staff in Thailand. As noted last year, many of the regional TB offices have been weakened because staff posts have been cut and additional duties have been assigned to existing staff. A comprehensive HR development plan has been prepared; the immediate challenge is to ensure that sufficient funding is available to implement it.
Referral and transfer systems between treatment units and between prisons and MoPH facilities are weak. Timely information is often not communicated and there is no specific budget for communication between provinces. A TB network meeting was held in 2003 for the TB coordinators of the 12 regions, Bangkok and the prison service to address the referral and transfer system and overall strengthening of the TB network. Efforts are being made to improve data collection, and there are plans to introduce an electronic data management system.
The recent DOTS expansion to marginalized population groups including people living in border areas, migrants, prisoners and the urban poor have contributed to the high case detection rate in Thailand. NGOs and other organizations outside the MoPH system have been particularly active in expanding DOTS services to these groups.
Funding for anti-TB drugs has been adequate in the past but may be threatened if the purchase of drugs must be financed from fixed province and district budgets. Currently, most anti-TB drugs used by the NTP are manufactured in Thailand and are more costly than internationally procured drugs. Renegotiating prices with the government pharmaceutical organization or exploring additional procurement channels may help to release local funds for other TB-related activities such as training and supervision. The prevalence of MDR-TB among new cases decreased from 2.1% in 1997 to 0.9% in 2001. A nationwide drug resistance survey is planned for 2005. At present, the NTP does not diagnose and treat MDR-TB patients. However, policy guidelines on MDR-TB management are being developed.
Three 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
Compared with most other HBCs, Thailand has relatively well-equipped laboratories with few supply or maintenance problems. Thailand is planning to broaden the range of diagnostic services for TB by developing further capacity for doing TB culture in provincial hospitals and by strengthening the existing culture facilities of regional TB reference laboratories. The rapid detection of drug resistance is a priority for the NRL. EQA activities cover all TB laboratories in MoPH facilities, and efforts are to being made to include the private sector in the quality assurance scheme. Laboratory training activities are being expanded to include training for all TB control staff and targeted training for laboratory staff in technical areas where laboratory performance needs to be improved.
The estimated prevalence of HIV in Thailand (1.5% of adults aged 15–49 at the end of 2003) is the highest in the WHO South-East Asia Region. The prevalence of HIV among TB patients in sentinel surveys was between 10% and 15% in the country as a whole, but up to 30% in some regions (higher than the WHO estimate of 9% of adult TB patients). A national TB/HIV coordinating body was first established in 2001 and a national TB/HIV strategy has been in place since 2004. National TB/HIV guidelines were prepared in 2004 and will be implemented in January 2005.
VCT is offered to all TB patients in four pilot provinces: Chiang Rai, Ubon Ratchathani, Phuket and two districts in Bangkok. Data on specific indicators such as the proportion offered counselling, the proportion tested and the proportion found to be HIV positive will be collected and analysed. It is planned to train all TB clinic staff in the country in VCT by 2005.
Links with other health-care providers
The NTP has established a task force for PPM DOTS and has begun to collaborate with some private hospitals, private physicians and NGOs. There is a need to strengthen ties with all public sector providers and institutions involved in TB treatment and diagnosis, especially since the health-sector reform process has led to a more diversified network for delivering TB care. Public hospitals throughout the country are involved, but the participation of medical colleges and of prison and military health services remains limited.
CDC, RIT and WHO are the main technical partners in Thailand, assisting with DOTS expansion and TB/HIV activities. CDC (USAID) and GFATM are the major funding partners for surveillance, laboratory services, training and collaborative TB/HIV activities.
Budgets and expenditures
Comprehensive data on NTP budgets and expenditures are not available for the period 2003–2005. This is because, under the new health insurance scheme introduced in 2003, provincial and district hospitals receive budgets (calculated on the basis of fixed per capita rates) to provide a package of clinical care. It is not clear how much funding for the TB control programme is provided from these budgets. Meanwhile, programme support functions such as training and supervision are covered through a separate budget. Budget figures reported to WHO for 2004 and 2005 therefore reflect only the budget managed by the TB cluster in Bangkok. As a result, the reported budget has fallen from US$ 6.1 million in 2002 to US$ 4.7 million in 2005, despite an increase in funding from the GFATM. The development of national budgets in future will depend on the NTP’s ability to implement a comprehensive financial monitoring system that allows budgets and available funding to be reported by all provinces and districts. Estimates made in previous WHO reports indicate that the total cost of TB control is about US$ 10 million per year, and around US$ 170 per patient treated.