Planning and DOTS implementation
TB control in the context of the health-care system
Country profiles incorporate information from the summary planning tables that were prepared for the 2004 DEWG meeting and from the questionnaires submitted by all 22 HBCs. The health systems of many countries are still undergoing reform and restructuring. However, all HBCs except the Russian Federation and Thailand reported that TB control functions are fully integrated with essential national health services. The MoH generally provides support for TB control through a specific technical unit, although in Bangladesh, South Africa and Thailand this function needs to be strengthened. All HBCs have a national plan for TB control and many will conduct, during 2005, a new planning exercise for the next five years. A total of 15 HBCs have prepared, or are developing, a plan for human resource development (HRD) reflecting their specific needs in the context of the health system.
Constraints and remedial actions
In summary tables and questionnaires, countries reported the following constraints:
1. Shortage or inadequate capacity of staff. This remains a major constraint identified by 18 HBCs. The problem is being addressed by various means: situation assessments, development of HRD plans, intensification of training and supervision, redistribution of staff and appointment of new staff. All HBCs except Brazil, Nigeria, South Africa and Zimbabwe plan to implement projects funded by the GFATM in 2005; a shortage of managers, or inadequate managerial capacity, will almost certainly hinder these projects.
2. Inadequate central management capacity. Insufficient capacity at the highest levels delays the implementation of national plans, as reported in Bangladesh, Mozambique, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe. Support from technical partners has been the main temporary remedial action.
3. Inadequate infrastructure. Lack of transportation infrastructure (roads and vehicles), poor communication networks, unreliable or non-existent electricity supplies, inadequate buildings and equipment, and weak primary health-care systems all impede TB control. A total of 12 HBCs reported deficiencies in at least one of these areas.
4. Weak political commitment. Ethiopia, Mozambique, Nigeria, South Africa, Thailand and Zimbabwe reported limited commitment to TB control from central and peripheral levels. Remedial actions include providing better support to local government following decentralization, forming provincial task forces, expanding international support through high-level advocacy missions and advocacy for TB control in civil society, especially in support of patients infected with HIV. Brazil, China and the Russian Federation reported significant progress on legislation to support TB control.
5. Weak laboratory services. The main obstacles are summarized in Table 11.
6. Nearly all HBCs had a secure supply of anti-TB drugs in 2003, thanks in large part to the Global TB Drug Facility (GDF). Mozambique reported drug shortages, but these will be rectified following a successful application to the GDF. South Africa experienced drug shortages due to the phasing in of the new drug combinations and a complete stock-out of streptomycin when the sole supplier stopped production.
7. Poor monitoring and evaluation. Timely and reliable data are essential for monitoring trends and for planning corrective actions. The Russian Federation and South Africa have addressed problems reported in 2003 13 by establishing standardized recording and reporting systems. China has introduced a new Internet-based reporting system, but the data being collected need validation.
8. Insufficient funds. A lack of money is no longer one of the major constraints identified by most HBCs. The governments of the wealthier HBCs make large contributions to TB control, international donors have increased their investments and the GFATM has begun to bridge financial gaps. As a result, some NTPs now have sufficient funding to expand DOTS programmes. However, some of the HBCs did report shortfalls in their 2004 budgets. Some of these countries still report gaps (see section on Financing DOTS Expansion), and others have problems in distributing funds from local or central governments to programmes (e.g. Nigeria). Mozambique has inadequate funds to pay salaries, and Zimbabwe is heavily affected by the country’s general financial crisis.
9. Poor access to remote areas. Access to geographically remote and politically unstable areas is a challenge in Afghanistan, Bangladesh, the Philippines and Uganda. The NTP in Viet Nam, having reached the targets for DOTS implementation, has made service provision in remote areas an important part of consolidating programme success.
10. Low public awareness. Limited knowledge about TB and its treatment, and the stigma of having TB (and perhaps also HIV infection), both hamper efforts to detect and treat TB suspects. A total of 13 HBCs have plans to launch or intensify advocacy and communication campaigns.
Intensified support and action in countries
During 2004, the DEWG launched ISAC, an emergency initiative to reach targets for DOTS implementation by 2005 and to generate further momentum towards the MDG targets for 2015. The goal of ISAC is to rapidly increase managerial capacity for TB control at central and intermediate levels of administration. Participating countries include China, India, Indonesia, Kenya, Pakistan, Romania, the Russian Federation and Uganda.
Partnerships, coordination and advocacy
All HBCs have some mechanism for coordinating TB control activities. Most countries have an NICC that meets regularly to share information on planning and progress. This has served as a model for the creation of Global Fund Country Coordination Mechanisms (CCMs). However, in some countries (e.g. Ethiopia, Viet Nam) the CCM has become the main coordinating body. During 2004, Indonesia, Pakistan and Uganda formed and launched national partnerships to Stop TB, in order to establish collaborations among various stakeholders (NTP, WHO, technical and financial partners, NGOs, and patients’ associations), and to share human and financial resources to address more effectively some of the constraints hindering NTP performance. NGOs are actively collaborating with NTPs to improve service coverage in 20 HBCs (Annex 1).
Most of the HBCs recognize the need for improved advocacy and communication on TB control. Ethiopia, India, Kenya, Pakistan, South Africa and Viet Nam reported that such activities were intensified in 2004. Cambodia, the Democratic Republic of the Congo, Indonesia, Nigeria, the Philippines, the United Repbulic of Tanzania and Uganda are planning advocacy and communication campaigns for 2005.
Management of drug resistance
Among the HBCs, Kenya (pilot site in Nairobi), the Philippines (pilot site in Manila) and the Russian Federation (Archangelsk, Ivanovo, Orel and Tomsk oblasts) have DOTS-Plus pilot projects approved by the GLC. The projects in Kenya and the Philippines are supported financially by the GFATM, as is one of the four projects in the Russian Federation (Tomsk). In 2005, applications to the GLC are expected from Bangladesh, Myanmar, the Philippines, the United Republic of Tanzania and Viet Nam.
By December 2004, the GLC had approved 30 DOTS-Plus pilot projects for a total of 10 133 MDR-TB patients in 23 countries. 25 However, only three HBCs – Brazil, the Russian Federation and South Africa – have national policies for the diagnosis and treatment of MDR-TB, and manage MDR-TB under the NTP. Even in the few countries that do have policies, MDR-TB treatment often fails to meet acceptable standards in practice. Second-line drugs are available in almost all HBCs, and are locally produced in Bangladesh, Brazil, China, Kenya, India, Indonesia, the Philippines, Pakistan, the Russian Federation, South Africa, Thailand and Viet Nam. In many countries, substandard MDR-TB treatment is available in the private sector or at specialized health centres, often for a fee.
The planning of activities related to MDR-TB is described in the individual profiles of the 22 HBCs (Annex 1).
Collaborative TB/HIV activities
Among the 199 countries that completed the WHO data collection form, 49% have a national policy of offering HIV testing to TB patients, the first step in accessing appropriate prevention and care services for HIV-positive TB patients. However, in 2003, only 3% of 4.4 million notified TB cases were reported to have been tested for HIV. Of these 199 countries, 46 (23%) indicated that HIV-positive TB patients were routinely assessed for their eligibility for ART. Only 1349 TB patients were reported to have started ART in 2003.
Figure 23 shows the breakdown of HIV testing rates among TB patients by country, for all countries that notified more than 1000 TB patients in 2003 and tested more than 1% of them for HIV. Even in Brazil, where ART is provided free of charge in the public sector, only half of the notified TB patients were reported to have been tested for HIV. Among other countries that notified more than 10 000 cases each year, Côte d’Ivoire tested less than 30%. Botswana, Cameroon, Malawi, Namibia and South Africa tested about 10%. For other high-incidence countries, the proportions tested were still lower. Some countries with low TB incidence rates, including Cuba and Latvia, tested most of their TB patients.
Regional differences in HIV testing, and in assessment for and provision of ART, are shown in Figure 24, where the denominator is the estimated number of new HIV-positive TB patients in 2003. Under normal circumstances, several TB patients would have to be tested in order to detect one HIV-positive patient. Thus the number of patients tested for HIV should be several times greater than the number estimated to be HIV positive, but the number tested exceeded the estimated number only in the Region of the Americas, European Region and Western Pacific Region.
By region, as by country, the number of HIV-positive TB patients who were assessed for ART is much smaller than the number who were tested for HIV. In the Region of the Americas, seven HIV-positive TB patients were assessed for ART for every 100 estimated to be HIV-positive, and most of these were in Brazil. In the African Region, the region worst affected by HIV/AIDS, only four patients were assessed for ART for every 1000 HIV-positive TB patients. The percentage of HIV-positive TB patients reported to have started ART was still lower. The Region of the Americas performed better than other regions, but fewer than four out of 1000 HIV-positive TB patients started ART.
Of the supplementary questionnaires sent to 41 high-incidence countries, 32 were returned to WHO. The data show that, between 2002 and 2003, TB/HIV collaboration had improved (Figure 25). However, implementation and recording and reporting remain weak. For example, few countries were able to report the exact numbers of TB patients or HIV-infected people that were benefiting from these activities.
Additional strategies for DOTS expansion
Public public and public private mix for DOTS (PPM). During 2004, 13 HBCs reported improved links between the NTP and other health-care providers (Table 12); 14 have established better collaborations with medical colleges; 10 have PPM pilot projects in various stages of implementation. Seven more HBCs are planning PPM initiatives for 2005, and four (India, Kenya, Myanmar and the Philippines) are attempting to implement PPM initiatives nationally. China, India, Indonesia, Kenya and Pakistan have specific plans to scale-up collaborations between NTP and non-NTP public hospitals.
Community TB care. A total of 17 HBCs reported some form of community contribution to TB care. In Bangladesh, India and Uganda, NGOs and community groups have played a vital part in expanding access to TB treatment. Communities are involved in TB care in limited parts of Afghanistan, Cambodia, China, the Democratic Republic of the Congo, Ethiopia, Indonesia, Kenya, Mozambique, the Philippines, South Africa, the United Republic of Tanzania and Viet Nam. Nigeria is planning to carry out a pilot study in 2005.
Practical Approach to Lung Health (PAL). Cambodia, the Democratic Republic of the Congo, Indonesia, Mozambique, Nigeria, Russian Federation, the United Republic of Tanzania, Uganda and Viet Nam are planning to investigate the feasibility of implementing PAL in 2005. These studies will investigate how the syndromic approach to diagnosis and treatment can influence TB case detection and the rationalization of drug prescription practices.
13 Global tuberculosis control: surveillance, planning, financing. WHO report 2004. Geneva, World Health Organization (WHO/HTM/TB/2004.331).
25 Bolivia, Costa Rica, El Salvador, Egypt, Estonia, Georgia, Haiti, Honduras, Jordan, Kenya, Kyrgyzstan, Latvia, Lebanon, Malawi, Mexico, Nepal, Nicaragua, Peru, Philippines, Romania, Russian Federation, Syrian Arab Republic and Uzbekistan.