Global TB Control 2009 - A Health Systems Update
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The WHO has recently published the Global TB Control Report 2009 ("2009 Report"). There is progress in meeting the TB-related MDG targets, but it is not sufficient nor universal across the world. Viewing the blockages to achievement of TB targets through a health systems lens has acknowledged relevance in Africa and Asia. This blog entry reviews the priorities in this regard.
WHO Global TB Control Report 2009 Summary: The main targets for global TB control are that the rate of new cases of TB should be falling by 2015, TB prevalence and death rates should be halved by 2015 compared with their level in 1990, at least 70% of new smear-positive cases should be detected and treated with DOTS, and at least 85% of new smear-positive TB cases should be successfully treated. The data collected for the 2009 Report indicate that the new case (incidence) rate has been falling since 2004, that prevalence and death rates will be halved in at least three of six WHO regions by 2015 compared with a baseline of 1990 (Africa and Europe regions will miss the target), that the case detection rate reached 63% in 2007 (compared to a target of 70%), and treatment success rate reached 85% in 2006 (the target).
Has the TB situation got better in Africa?
While there have been sterling achievements in some parts of the world, in other parts thing may be getting worse. In 2005, WHO declared a 'TB emergency' in Africa. Has much changed for the continent since then, given the tone of cautious optimism in the 2009 Report? If judged on prevention of new cases, it seems not. In 1990, India and all countries in sub-Saharan Africa fell in the incidence range 100-200 cases per 100,000. In 2007, India has the same incidence rate as in 1990. But, sub-Saharan Africa is much worse off. Based on data from 2007, all the countries in the highest TB incidence bracket - 300 cases or more per 100,000 - are in sub-Saharan Africa. Incidence as a whole is rising (Figure 1).
Figure 1: Change in estimated TB incidence rate, 1990-2007. Source: WHO 2009 Report
In fact, of the 25 highest incidence countries in the world in 2007, all but one were in Africa. Africa's HIV epidemic during the 1990s and 2000s has a lot to do with this. As a very crude measure, the correlation between the TB incidence rate (all types of TB) and the HIV prevalence rate per 100,000 in those aged 15+ for 2007, among the top 17 countries with the highest TB incidence (at least 400 cases of per 100,000), was 0.7. In 23 countries with TB incidence between 100 and 200 cases per 100,000 (that had a HIV prevalence rate figure for 2007), the correlation was only 0.27. Much the same conclusion could be identified by graphing the two epidemics over time on any related indicator. The highest TB-HIV coinfection rates are in Southern Africa (above 50% of new TB cases are HIV+ here). Additionally, the complex and worrying situation with the emergence of MDR-TB (and XDR-TB) in Southern Africa deserves its own blog post.
The case detection rate (proportion of the estimated new smear-positive TB cases that are detected and notified) has been nearly flat over recent years in the WHO Africa region (Figure 2).
Figure 2: Smear positive case detection rate under DOTS by WHO region, 1995-2007. Source: WHO 2009 Report
There is still cause for some optimism - in the high TB/high HIV countries (Figure 1, on left), there has been some reduction in the TB incidence rate in the very recent past. Treatment success rates (cure plus completion) in the African high TB burden countries (N=9 by the WHO count) have improved since the 1990s, and the 2006 cohort value was 75% (target=85%), much the same as the previous three years. This achievement is impressive, but implies a plateau of improvements.
But at what cost for these small gains? Figure 3 shows the increase in the budget of National TB Programs (NTPs) in all 22 High TB Burden countries (this does not include other government funding for TB control and treatment, and cost to general health services, which are available in the 2009 Report, along with footnotes to the NTP budgets). There has been a 175% increase on the total NTP budgets in 2002, with DOTs and MDR-TB still accounting for most of the funding. Given an implied sustainability problem, the annual increase in budgets has slowed, as Figure 3 demonstrates. Given this slowing in funding increase, how will the big challenges of TB control in sub-Saharan Africa be solved?
Figure 3: NTP budgets by line-item, high TB burden countries, 2002-2009. Source: WHO 2009 Report
If not, what can we do for TB with health systems?
The slow improvement in the TB impact indicators in the high burden countries of sub-Saharan Africa has a lot to do with systemic deficiencies. Individual health workers in underfinanced and understaffed DOTS clinics in such countries are achieving miracles in service delivery as I have personally witnessed. However, the support system and the plan for extending, improving, and sustaining such work is rarely present where it is needed the most. The following extract from the report of the DOTS Expansion Working Group may summarize what I mean:
"Many NTPs today struggle to implement high-quality services in the context of health workforce crises, continuous low levels of public funding for health care, weak government stewardship functions and disintegrated health service networks. DOTS expansion itself is one facet of health systems development. To invest in DOTS means investing in improved health systems. However, DOTS expansion without strengthening of general health services is not sustainable." (Source: DOTS Expansion Working Group Strategic Plan 2006-2015, WHO 2006)
Is there some strategy combining TB and health system thinking in the present? The 2009 Report makes the following linkages with health system strengthening:
- Institution of the International Health Partnership (IHP+) established in September 2007, which aims to accelerate the scale-up of health services via the development and implementation of “country compacts”. As of end-2008, 10 countries had been IHP+ compacts: Burundi, Cambodia, Ethiopia, Kenya, Madagascar, Mali, Mozambique, Nepal, Nigeria and Zambia.
- Integration of TB control in primary healthcare: Twenty high burden countries or HBCs (and 83% of all countries) reported that TB control services were delivered through PHC facilities. Similarly, laboratory services for diagnosis of TB are usually integrated into general laboratory services. Procurement, distribution and stock management of anti-TB drugs are undertaken together with other essential drugs management in 10 HBCs and in 64% (110/173) of all reporting countries.
- Alignment with broader planning and financing frameworks: A high proportion of HBCs reported alignment of NTP plans and budgets with broader planning and financing frameworks. Contributing to health-system strengthening is an explicit component of the national strategic plan for TB control in 19 HBCs.
- Human resources for health development: The 2008 data indicate that major strengthening of HRD for TB control is urgently needed in many countries in all regions, especially in HBCs. There is a need to ensure both financing and guidance for an adequate, competent and performing workforce for TB control, integrated within overall health workforce plans and strategies. A total of 94 countries including 14 HBCs have conducted a recent needs assessment, and 90 countries including 14 HBCs have a comprehensive plan for HRD for TB control. Among the HRD plans that do exist, most could be strengthened (see the 2009 Report on details).
- Infection control: Measures to control infection need to be implemented throughout the health system. While some measures are TB-specific, others are relevant to all infectious diseases. The importance of implementing these measures has been highlighted by the transmission of MDR/XDR-TB in settings where HIV care is provided.
- Practical approach to lung health (PAL): PAL is a patient-centred approach to improving the quality of diagnosis and treatment for common respiratory illnesses in primary healthcare facilities. It is designed to ensure a consistent approach to diagnosis and treatment at different levels of the healthcare system, efficient use of resources, and coordination among TB control services and other health-care services. At the end of 2008, 70 countries including nine HBCs had a plan to initiate PAL. Nine countries were piloting PAL and 11 were in the process of expanding it beyond pilot sites (including one HBC, South Africa). National guidelines for PAL were available or in preparation in 21 countries.
The steps outlined above in the current Stop TB strategy are mostly for better alignment of the TB control program in a country and the general healthcare setting. However, there is little thinking here of how other interventions or advances in the health system will assist in improved DOTS. In a future blog post, I will consider what such linkages could be in the context of better TB outcomes.
From DDS San Antonio on 3 July 2009, 02:16
This is a very informative article about TB. We hope that health care system improves, a long side with the health care conditions of our people.