Better treatment and care for TB patients

TB-REP was a multipartner project aiming to prevent TB and drug-resistant TB and to improve TB treatment outcomes by increasing political commitment and adopting people-centred models of care. Advocacy and civil society engagement were key project components.

TB-REP supported 11 countries of eastern Europe and central Asia: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. These are among the high-priority countries for TB in the WHO European Region and have a total population of more than 140 million.

In 3 years (2016–2018), TB-REP sought to translate existing good practices at the country level into people-centred models of TB care, and to replicate them across project countries. TB-REP’s specific objectives included:

• the adoption by countries of key policies on people-centred TB service delivery, TB care financing and human resources for TB programmes;
• the rational use of hospital care, based on clearly defined and adopted admission and discharge criteria;
• the development of country roadmaps to incorporate people-centred policies for sustainable and effective TB prevention and care.

Several partners jointly implemented TB-REP: civil society organizations; the Center for Health Policies and Studies, Republic of Moldova (principal recipient) and WHO/Europe (key technical partner and co-leader). WHO/Europe provided strategic guidance and technical advice, and facilitated dialogue among countries. The Global Fund to Fight AIDS, Tuberculosis and Malaria provided financial support.

Main achievements

TB-REP supported a change in mindset, at both political and provider level, facilitating the re-organization of TB treatment and care. This change helped many participating countries to move towards more people-centred TB service delivery and/or to adopt improved health financing mechanisms and new approaches to planning human resources. As a result, duration of hospital stay and hospitalization rates – both indirect measures of people-centredness of care – were reduced.

TB-REP also managed to increase the prominence and engagement at national level of civil society in the TB response.

Specific achievements include:

• TB-REP developed a blueprint of policy options to design a people-centred model of TB prevention and care. This model focuses on meeting the health needs and expectations of people throughout their life-course through a strong primary health care system and community.
• TB-REP developed several practical tools supporting countries’ implementation of a people-centred model of TB care. These include a bed forecasting tool, a human resource assessment tool and a regulatory framework assessment tool.
• Using the blueprint, countries participating in the project took different approaches, depending on their health systems and transformation agenda. When the project started in 2016, less than half (45%) of the participating countries had adopted key policies on health system strengthening and TB; in 2017, this percentage had grown to more than 73% for people-centred TB prevention and care policies – an increase of nearly 50%.
• Armenia, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Uzbekistan introduced people-centred national TB policies. A few participating countries had not introduced formal policies for a people-centred model of TB care as of 2017, but are strengthening TB services and taking steps towards a more ambulatory-based TB care. Some countries developed and implemented roadmaps, several of which were endorsed by their governments.
• Belarus, Kazakhstan and Kyrgyzstan developed mechanisms to sustainably fund outpatient care.
• Nationally assigned civil society organizations that were TB-REP partners collaborated with national authorities to foster and catalyse the transition to people-centred models of TB care within their areas of responsibility, advocated in their country for quality TB services and represented those most vulnerable to TB.

Lessons learned

• Changing the mentality of policy-makers, medical staff and patients on the best ways to manage and treat TB was crucial to unlock change. TB-REP partners analysed the reasons for resistance, which differed across countries, and addressed them with patience and persistence to change the perception of how health systems should be organized.
• The level of interest and preparedness for change determined the extent of the transformation in each participating country. While change takes time and not all countries might achieve the highest possible level, support should not stop.
• TB-REP supported change by facilitating the exchange of experiences, ideas and inspiration on how to overcome challenges. Bringing stakeholders together in each country has helped to create a common understanding of the challenges and a shared language. This collaboration should continue.

Advocacy and civil society engagement in TB-REP

Advocacy and civil society-oriented partners in the Tuberculosis Regional Eastern European and Central Asian Project (TB-REP) were involved in advocating in their country for quality TB services and ensuring that decision-makers hear the voices of those most vulnerable to TB. At national level, TB-REP managed to increase the prominence and engagement of civil society in the TB response.

With guidance and support from project leaders (the Center for Health Policies and Studies, Republic of Moldova; and WHO/Europe), nationally assigned civil society organizations collaborated with national authorities to foster and catalyse the transition to people-centred models of TB care within their areas of responsibility. Activities included:

• contributing to the documentation of country experiences and lessons from collaborating partners;
• conducting bottom-up regional and national advocacy programmes to engage countries;
• strengthening the implementation of people-centred models of TB care by supporting country-specific adaptation based on the perspectives of civil society organizations.