Viet Nam is the only member of the current group of HBCs 9 to have reached the targets for DOTS implementation, which were achieved before 2000 and exceeded subsequently. This outstanding success was made possible by the effective integration of political commitment, international technical assistance and funding, and efficient community mobilization. Viet Nam has continued to expand the programme so as to reach remote population groups who have not had access to TB services, and to strengthen the diagnostic laboratory network. An urgent priority is the development of a national plan for improved TB/HIV coordination. A planned national TB prevalence survey will be of critical importance for measuring the impact of DOTS on the TB epidemic. Because of its success in achieving the targets, Viet Nam does not need substantial budget increases in 2005.
System of TB control
The National Hospital of Tuberculosis and Respiratory Diseases, in Hanoi, is responsible for the activities for all of Viet Nam. Pham Ngoc Thach Hospital in Ho Chi Minh City is appointed to supervise the activities for the southern provinces. Each province has a provincial TB centre, under the direction of the provincial health service, which is responsible for the local implementation of the TB control programme. The district TB units, directed by the district health centres, coordinate the operation of peripheral TB activities. TB patients are referred to the district health centres from community health posts for sputum examination and initial treatment.
An effective national TB laboratory network operates under the supervision of the NTP. There are two reference laboratories (Hanoi and Ho Chi Minh City) that perform culture and drug susceptibility testing. Of the 64 provincial TB laboratories, nearly one quarter perform culture. Smear microscopy services are provided by more than 600 district TB laboratories.
Surveillance and monitoring
The best estimates of case detection for 2003 (86%) and treatment success for the 2002 cohort (92%) suggest, as in previous years, that Viet Nam has comfortably exceeded the targets for DOTS implementation. Given that DOTS coverage and case detection and cure rates have been very high since 1997, a fall in the incidence rate could be expected, which should be reflected in the trend in case notifications. It is unclear why no such decline is visible in the nationally aggregated data, but analysis by province could be more illuminating. Case-notification rates are highest among elderly men and women, suggesting that TB incidence has been higher in the past. It is possible that incidence is not falling perceptibly in Viet Nam because the case detection rate may be lower, and the incidence rate higher, than the WHO estimates. In this context, Viet Nam’s long-planned prevalence survey would help to establish the true burden of TB in the country, as well as providing a baseline against which to evaluate the impact of the programme on the TB epidemic.
Improving programme performance
Although all provinces maintain 100% coverage by the DOTS strategy, there are populations living in remote and mountainous areas with limited access to DOTS services. The NTP is expanding DOTS to reach these areas while maintaining excellent services. Efforts to reach these remote populations and other vulnerable groups started in 2003 and continued in 2004. Maintaining a consistent supply of high-quality anti-TB drugs for the entire country, especially in newly covered areas, is another important challenge being addressed by the NTP. A regulatory framework and enforcement mechanism have been developed to ensure the high quality of anti-TB drugs for TB services both within and outside the NTP. The feasibility of using FDCs for patients living in areas which are difficult to access is being explored. The last drug resistance survey was carried out in 1996 and estimated the prevalence of MDR-TB at 2.3% among new cases. A new survey is scheduled for 2005.
The NTP is developing the next five-year plan for TB control (2006–2010). Human resource capacity development will continue to be a priority, and the NTP will work with local authorities to recruit and maintain existing staff and to develop intensified training activities for staff at all levels.
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 and the community.
Diagnostic and laboratory services
As DOTS services are expanded to remote and mountainous regions, diagnostic services also need to be provided to these areas. An EQA system for sputum microscopy based on new international guidelines is being established in laboratories at district level throughout Viet Nam. In 2004 and 2005, staff in 20 of 64 provinces will be trained on the EQA system, and methods will be developed to implement and maintain EQA throughout the country.
In 2002, the prevalence of HIV in new TB patients was estimated to be 3% based on HIV sentinel surveillance among TB patients. This is somewhat higher than the WHO national estimate of 1.8%. In 10 provinces HIV prevalence exceeded 3%, and in two provinces (Binh Duong and Haiphong) the prevalence was more than 10%. In An Giang Province a pilot project included the use of isoniazid preventive therapy for PLWHA infected with M. tuberculosis, and co-trimoxazole preventive therapy for TB patients with HIV coinfection. ART for HIV-infected TB patients is not yet available. There is an urgent need for a well-defined national plan for TB/HIV coordination, including strategies for TB prevention and control for PLWHA, HIV/AIDS prevention, and health promotion and treatment for TB patients.
Links with other health-care providers
Private providers treat a considerable proportion of patients in metropolitan Ho Chi Minh City, but the situation is uncertain in other parts of the country. A project aimed at involving private providers in TB control in Ho Chi Minh was implemented from 2001 to 2004 with mixed results. Case notification increased, but the treatment success rate was poor in the private clinics involved, probably because anti-TB drugs were not provided free of charge. No other private sector initiatives have been undertaken.
Links with the community
The community (i.e. villages, Women’s Union, Farmer’s Union) is involved in a successful IEC campaign for TB control activities, and there are plans to scale up these activities.
Effective international partnerships are a major feature of Viet Nam’s TB control programme. Viet Nam’s longstanding relationship with the Medical Committee Netherlands Viet Nam and, more recently, technical and funding partnerships with KNCV and the Dutch Government, have created nationwide TB services of high quality. A grant from the GFATM (signed in late 2003) is being used to reach TB patients among high-risk groups, remote populations and PLWHA. WHO and CDC provide technical and financial support for TB control activities, and CDC operates a Global AIDS Programme office in Viet Nam. A World Bank loan assists with purchase of anti-TB drugs.
Budgets and expenditures
The NTP budget has consistently been about US$ 11–13 million per year between 2002 and 2005. Unlike most other HBCs, there has been no need for large increases in the budget during the period 2002–2005 because case detection and treatment success rates were already at target levels in 2002. Nevertheless, some budget increases have been planned, for example to allow better access to DOTS in remote areas and for a national prevalence survey.
Most funding is provided by the government (including loans), but grants also make an important contribution, and GFATM funding accounts for about 13% of the budget in 2005. Actual expenditures in 2003 were very similar to the planned budget. The NTP budget is consistently about US$ 120–140 per patient treated, while the total cost of TB control (including a network of dedicated hospital beds for TB patients and visits to clinics for DOT and monitoring during treatment) is consistently about US$ 250–300 per patient treated. The total estimated cost of TB control has remained stable at US$ 24–30 million per year.
9 Peru was excluded from the original group of HBCs, having met the targets and successfully reduced incidence.