WHO report 2008
Global tuberculosis control
2.4 Health system strengthening
Apart from PAL implementation and human resource development (HRD), questions about the strengthening of health systems were sent to HBCs only; findings in sections 2.4.1 and 2.4.3 below therefore refer only to HBCs.
2.4.1 Integration of TB control within primary health care
With a few exceptions, both TB diagnosis and TB treatment are fully integrated into the general health system. Laboratory services for TB diagnosis are integrated into general laboratory services in 15 of the 22 HBCs, and treatment is delivered through the general primary health care (PHC) network in all but two HBCs (China and the Russian Federation). General health-care staff are normally responsible for TB management in PHC settings, although seven HBCs have staff dedicated to TB control at PHC facilities such as clinics (Bangladesh, Brazil, China, Ethiopia, Mozambique, Myanmar and Nigeria). Distribution of anti-TB drugs is fully integrated into general drug distribution in 10 HBCs.
2.4.2 Human resource development
Optimum HRD for TB control requires at least seven components: (i) a recent HRD needs assessment; (ii) a comprehensive plan for HRD that addresses both training and staffing needs for all components of the Stop TB Strategy; (iii) up-to-date job descriptions; (iv) staff who are assigned to work on HRD at the national level; (v) inclusion of TB in the training curricula of doctors, nurses and laboratory technicians; (vi) training for existing staff at all levels of the health system; and (vii) systematic monitoring of recruitment and training needs, for example to account for staff turnover.
Only half of the HBCs have conducted a recent HRD needs assessment, and 13 HBCs reported having a comprehensive plan for HRD related to TB control (Table 2.13). Six HBCs are without comprehensive HRD plans or a recent HRD needs assessment: Cambodia, the Democratic Republic of the Congo, Mozambique, the Russian Federation, Uganda and Zimbabwe.
Among the HRD plans that do exist, several could be strengthened. Only 11 countries have considered staffing needs for all of the four following components of TB control: DOTS implementation, MDR-TB, collaborative TB/HIV activities and PPM (Table 2.13). Other plans address training needs but not staffing needs (e.g. Nigeria and the Philippines).
Job descriptions of staff involved in the implementation of the Stop TB Strategy were up-to-date or almost all up-to-date (in line with current policies and recommendations) in 17 HBCs; exceptions were the Russian Federation (none up-to-date), and the Democratic Republic of the Congo, Mozambique, Nigeria, and Zimbabwe (some up-to-date).
The number of staff assigned to HRD at national level remains limited. On the positive side, 15 of the 22 HBCs have a designated person for HRD at the central level of the NTP. However, a full-time member of staff was available in only four countries: Bangladesh, Brazil, China and South Africa. Staff working full-time on TB control are available at provincial (or equivalent) level in 20 HBCs. Monitoring of staff availability and turnover appears weak across HBCs. Only 10 HBCs provided at least some information about the availability of staff trained in TB control in primary health-care facilities.
Training related to TB control is included in the basic curricula of doctors in 18 HBCs, and in the curriculum of laboratory technicians in 15 HBCs. However, training of teaching staff in medical and nursing schools is available in only nine HBCs, and training for teachers of laboratory staff is being provided in just seven HBCs.
Among HBCs and other countries, around 87 reported having conducted a recent HRD needs assessment, and 90 countries reported having a comprehensive HRD plan (Table 2.13). The number of plans that considered staffing and/or training needs for major components of TB control ranged from about 60 to 80 countries, depending on the component, while 117 countries reported having up-to-date or almost up-to-date job descriptions. In no region except the Eastern Mediterranean and the South East Asia did the number of countries reporting that a key component of HRD was in place exceed half of the number of countries in the region. Overall, these data show that major strengthening of HRD for TB control is needed in many countries in all regions.
2.4.3 Links between planning for TB control and broader health or public sector planning initiatives and frameworks
Given the level of integration of TB control activities within primary health-care services described above, TB control requires a well-functioning health-care system including NTP participation in efforts to strengthen health systems. Contributing to health system strengthening is an explicit component of the national strategic plan for TB control in 20 of the 22 HBCs. Beyond this, five of the most important examples of national plans and frameworks to which plans for TB control should be aligned are national health development plans, poverty reduction strategy papers, national human resource plans for health, medium-term expenditure frameworks and sector-wide approaches (SWAps). Among HBCs that reported the existence of these plans and frameworks, the extent to which alignment of the national plan and budget for TB control was reported varied (Figure 2.17). The proportion of countries reporting alignment with medium-term expenditure frameworks and SWAps was high, but there is much scope to increase alignment with national plans for HRD as well as general plans for health-care development.
2.4.4 Practical Approach to Lung Health
PAL is included in the national plans of 73 countries including 10 HBCs. By the end of 2006, 26 countries including three HBCs had prepared detailed plans to develop and implement PAL activities. Of these, 24 had established a national working group on PAL and 17 had produced national PAL guidelines. Seven countries were piloting or preparing for expansion, while eight countries were undertaking nationwide expansion of activities: Bolivia, Chile, El Salvador, Jordan, Kyrgyzstan, Morocco, South Africa and the Syrian Arab Republic. In 2007, five countries from the African Region including three HBCs (the Democratic Republic of the Congo, Ethiopia and Kenya) developed plans to initiate PAL implementation.