Strong general health care systems: a prerequisite to reach global tuberculosis control targets

Spatial analysis of tuberculosis treatment outcome in Shanghai: implications for tuberculosis control

Objectives

Tuberculosis (TB) treatment outcome is a key indicator in the assessment of a TB control program. We aimed to identify spatial factors associated with TB treatment outcome, and to provide additional insights into TB control from a geographical perspective.

Methods

We collected data from the electronic TB surveillance system in Shanghai, China and included pulmonary TB patients registered for the period from January 1, 2009 to December 31, 2016. We examined the association of physical accessibility to hospitals, autoregression term and random hospital effects with treatment outcomes in logistic regression models after adjusting for demographic, clinical and treatment factors.

Results

Of the 53475 pulmonary TB patients, 49002 (91.6%) had a successful treatment outcome. The success rate increased from 89.3% in 2009 to 94.4% in 2016. The successful treatment outcome rate varied among hospitals from 78.6% to 97.8%, and there were 12 spatial clusters of poor treatment outcome during the 8-year study period. The best fit model incorporated the spatial factors. Both the random hospital effects and autoregression terms had significant impacts on TB treatment outcome, ranking sixth and tenth, respectively, in terms of statistical importance among 14 factors. However, number of bus stations around home is the least important variable in the model.

Conclusion

Spatial autocorrelation and hospital effects are associated with TB treatment outcome in Shanghai. In highly-integrated cities like Shanghai, physical accessibility is not related to treatment outcome. Governments need to pay more attention to the mobility of patients and different success rate of treatment among hospitals.

Challenges, opportunities, and potential roles of the private primary care providers in tuberculosis and diabetes mellitus collaborative care and control: a qualitative study

Introduction

The comorbidity of tuberculosis and diabetes mellitus (TB-DM) is a looming global co-epidemic problem. Despite the Indonesian Government’s ongoing effort to impose regulation for collaborative TB-DM management, the involvement of private primary care providers (PPCs) has not been considered before the COVID-19 pandemic. This study aimed to capture the PPCs’ existing practices and explore their challenges, opportunities, and potential roles in the collaborative TB-DM services and control.

Methods

A descriptive qualitative research design was used to collect data. Two Focus Group Discussions (FGDs) were conducted with 13 healthcare workers (HCWs) from different private clinics and eight private/solo general practitioners (GPs) from Yogyakarta City, Indonesia. We triangulated these data with data from FGDs of HCWs community health centers (CHCs) and in-depth interviews of three regional health regulators, five hospitals staff members, and a representative of national health insurance. The discussions were audio-recorded, transcribed verbatim, and subjected to thematic analysis.

Results

PPCs have not been initiated into the implementation of the collaborative TB-DM programme. The themes identified in this study were health system-related barriers, knowledge and perception of HCWs, lack of implementation of bi-directional screening, and needs of multisector role. The potential roles identified for PPCs include involvement in health promotion, bi-directional screening, patient referral, and data reporting according to the TB-DM programme indicators. However, more thorough improvement of PPCs’ capacity and logistic supplies are needed to provide comprehensive TB treatment.

Conclusion

Although PPCs’ involvement in implementing collaborative TB-DM services has yet to be considered, their potential role should not be neglected. Therefore, it is essential to increase their involvement by enhancing their capacity and improving the Public-Private Mix. PPCs’ engagement should be initiated and maintained to ensure the sustainability of the programme.

Variation of tuberculosis prevalence across diagnostic approaches and geographical areas of Indonesia

Background

Tuberculosis (TB) has contributed to a significant disease burden and economic loss worldwide. Given no gold standard for diagnosis, early identification of TB infection has been challenging. This study aimed to comparatively investigate the prevalence of TB across diagnostic approaches (sputum AFB, sputum culture, sputum genetic test, and chest x-ray) and geographical areas of Indonesia.

Methods

Participant demographic variables and TB screening test results were obtained from the Tuberculosis Unit, Health Research and Development Agency, Ministry of Health (HRDA-MoH). The prevalence of pulmonary TB in populations aged 15 years and over was calculated using TB cases as a numerator and populations aged 15 years and over as a denominator. Variations across geographical areas and diagnostic approaches were expressed as prevalence and 95% confidence interval (CI).

Results

A total of 67,944 records were reviewed. Based on bacteriological evidence, the prevalence of TB per 100,000 in Indonesia was 759 (95% CI: 589.7–960.8) with variations across areas: 913 (95% CI 696.7–1,176.7; Sumatra), 593 (95% CI 447.2–770.6; Java-Bali), and 842 (95% CI 634.7–1,091.8; other islands). Also, the prevalence of TB varied across diagnostic approaches: 256.5 (sputum AFB), 545 (sputum culture), 752.2 (chest x-ray), and 894.9 (sputum genetic test). Based on sputum AFB, the TB prevalence varied from 216.6 (95% CI 146.5–286.8; Java-Bali), 259.9 (95% CI 184.2–335.6; other islands) to 307.4 (95% CI 208.3–406.5; Sumatra). Based on sputum culture, the TB prevalence ranged from 487.9 (95% CI 433.6–548.6; Java-Bali), 635.9 (95% CI 564.9–715.1; Sumatra), to 2,129.8 (95% CI 1,664.0–2,735.6; other islands). Based on chest x-ray, the TB prevalence varied from 152.1 (95% CI 147.9–156.3; Java-Bali), 159.2 (95% CI 154.1–164.3; Sumatra), to 864 (95% CI 809–921.4; other islands). Based on sputum genetic test, the TB prevalence ranged from 838.7 (95% CI 748.4–900.8; Java-Bali), 875 (95% CI 775.4–934.2; Sumatra), to 941.2 (95% CI 663.6–992.3; other islands).

Conclusions

The variation of TB prevalence across geographical regions could be confounded by the diagnostic approaches.

Trial registration

This study was approved by the Institutional Review Board of Chulalongkorn University (IRB No. 684/63).

Involving private practitioners in the Indian tuberculosis programme: a randomised trial

OBJECTIVES

To assess a multicomponent intervention to improve private practitioners (PPs) involvement in referral of presumptive pulmonary TB (PTB) cases to the Revised National TB Control Programme (RNTCP) for sputum examination.

METHODS

Randomised controlled trial. We randomly allocated all 189 eligible PPs in Tumkur city, South India, to intervention or control arm. The intervention, implemented between December 2014 and January 2016, included two sets of activities, one targeted at health system strengthening (building RNTCP staff capacity to collaborate with PPs, provision of feedback on referrals through SMS) and one targeted at intervention PPs (training in RNTCP, provision of referral pads and education materials and monthly visits to PPs by RNTCP staff). Crude and adjusted referral and PTB case-finding rate ratios were calculated with negative binomial regression.

RESULTS

PPs referred 836 individuals (548 from intervention and 169 from control arm PPs) of whom 176 were diagnosed with bacteriologically confirmed PTB. The proportion (95% confidence interval) of referring PPs [0.59 (0.49, 0.68) vs. 0.42 (0.32, 0.52) in the intervention and control arm, respectively], mean referral rate per PP-year [(5.7 (3.8, 8.7) vs. 1.8 (1.2, 2.8)] and smear-positive PTB case-finding rate per PP-year [(1.5 (0.9, 2.2) vs. 0.6 (0.3, 0.9)] were significantly higher in the intervention than the control arm. Stratifying by qualification, a statistically significant difference in the above indicators remained only among GPs and internists. Overall, surgeons, paediatricians and gynaecologists referred few patients. PP referrals contributed to 20% of the sputum smear positive PTB cases detected by RNTCP in Tumkur city (14% were from intervention arm PPs).

CONCLUSIONS

We demonstrated the effectiveness of a health system-oriented intervention to improve PP's referrals of presumptive PTB cases to RNTCP.

Spatial and non-spatial determinants of successful tuberculosis treatment outcomes: An implication of Geographical Information Systems in health policy-making in a developing country

This retrospective study aimed to address whether or to what extent spatial and non-spatial factors with a focus on a healthcare delivery system would influence successful tuberculosis (TB) treatment outcomes in Urmia, Iran. In this cross-sectional study, data of 452 new TB cases were extracted from Urmia TB Management Center during a 5-year period. Using the Geographical Information System (GIS), health centers and study subjects' locations were geocoded on digital maps. To identify the statistically significant geographical clusters, Average Nearest Neighbor (ANN) index was used. Logistic regression analysis was employed to determine the association of spatial and non-spatial variables on the occurrence of adverse treatment outcomes. The spatial clusters of TB cases were concentrated in older, impoverished and outskirts areas. Although there was a tendency toward higher odds of adverse treatment outcomes among urban TB cases, this finding after adjusting for distance from a given TB healthcare center did not reach statistically significant. This article highlights effects of spatial and non-spatial determinants on the TB adverse treatment outcomes, particularly in what way the policies of healthcare services are made. Accordingly, non-spatial determinants in terms of low socio-economic factors need more attention by public health policy makers, and then more focus should be placed on the health delivery system, in particular men's health.

Tuberculosis in developing countries: conditions for successful use of a decentralized approach in a rural health district

INTRODUCTION

This article reports the results and the lessons learned from implementing the decentralized approach to tuberculosis (TB) detection and treatment, embedded with Human Immunodeficiency Virus (HIV) co-infection in health district. The objective was to increase the TB screening indicators in the district using the common ways for offering care to patients in health district.

METHODS

Conducted from August 2006 to July 2007, this large-scale intervention using Non-experimental study Designs has implemented a decentralized approach for fighting against TB in Orodara Health District (OHD), Burkina Faso. Pretest-posttest design has been used for quantitative part using indicators in one hand, and postests-only design for the qualitative part in other hand. In the pretest-posttest design, the TB indicators from years before 2006 (from 2002 to 2005) were used as earlier measurement observations allowing examining changes over time. The decentralized approach was incorporated into the annual planning of the OHD. For the quantitative study design, indicators used were those from National TB Program in Burkina Faso: TB detection rate, incidence density of TB per 100,000 inhabitants per year, and HIV prevalence in incident TB cases with positive smears. Data entry and analysis employed Microsoft Access and Excel software. For the qualitative, in-depth interview was used in which a total of 16 persons have been interviewed. Discussions were tape-recorded and transcribed verbatim for analysis using the computer-based qualitative software program named QSR NVIVO.

RESULTS

There were a total of 99,259 outpatient visits during the study period: the7,345 patients (7.43%) presented with cough. Of the 7,345 patient having cough, 503 cases (6.8%) were declared chronic coughing. These 503 patients were screened for TB, including 35.59% whose coughing had lasted 10 to 15 days. We observed an increase in a measured variable was observed. The TB detection rate and incidence-density rate based on positive smears were 16.11% (11.00% in 2005) and 10.42 per 100,000 inhabitants per year (6.88 per 100,000 inhabitants in 2005), respectively. There were 29 patients positive for TB: 41.37% of these had cough lasting 10 to 15 days, 10.34% were also positive for HIV, and 68.97% were from rural areas. Health workers and patients reported satisfaction with the intervention. It was found that implementing a decentralized approach to TB prevention in rural areas is plausible and effective under some conditions: considering that health district system is functional; carefully designing the intervention for TB case management; setting up and implementing of decentralized approach including strong monitoring; and taking into account the all financing, community and volunteer involvement, evaluation of the cost savings from integrating specific donor funding, and being supported by regional and central levels including National TB program.

CONCLUSION

The study has shown that TB detection rate can be increased by implementing a decentralized approach to primary care. When carefully implemented, a decentralized approach is a suitable approach to TB and HIV prevention in rural and inaccessible settings.

[Thirty years of tuberculosis control in Cameroon: alternating "vertical" and "horizontal" health care delivery systems]

BACKGROUND

In sub-Saharan Africa, tuberculosis remains endemic despite reforms of health systems and the tuberculosis control organization carried out in the last decades.

METHODS

We conducted a retrospective study of tuberculosis control in Cameroon from the period 2009 back to 1980. Data were collected from documents and activity reports of tuberculosis control, and interviews with managers of the National tuberculosis control program.

FINDINGS

The history of tuberculosis control in Cameroon from 2009 back to 1980 can be divided into three main periods. The first period, from 1980 to 1994, corresponded to the implementation of the 'primary health care' policy. At that time, tuberculosis case management was delivered free of charge, but centralized in specialized services with a gradual and mild increase in new cases detected. The second period, from 1995 to 2000, was characterized by the implementation of the 'primary health care reorientation' policy that decentralized tuberculosis care to all health facilities, but introduced cost recovery --which came along with a dramatic drop in the number of tuberculosis cases detected. The National tuberculosis control program, established in 1996, entrusted health facilities--especially hospitals--with the responsibility of tuberculosis diagnosis and treatment, and referred to them as tuberculosis diagnosis and treatment centers. During the third period, from 2001 to 2009, owing to major support from global health initiatives, the number of tuberculosis diagnosis and treatment centers was increased (reaching 216 centers in 2009), with a significant increase of new cases detected that peaked in 2006, from where the situation started declining till 2009.

CONCLUSION

Tuberculosis control indicators have never been optimal in Cameroon, despite the generally positive trend from 1980 to 2009. The strategy of tuberculosis diagnosis and treatment centers, which are essentially nested within hospitals, seems to have reached its intrinsic limitations. Better performance in tuberculosis control will henceforth require greater decentralization of tuberculosis detection and treatment to health centers. This careful decentralization will improve access for tuberculosis patients and lead to a comprehensive use of hospital technical expertise for tuberculosis care.

Uncovering the potential of private providers' involvement in health to strengthen comprehensive health systems: a discussion paper

Health systems strengthening (HSS) is being increasingly recognized as a strategic cross-cutting issue in all World Health Organization (WHO) work. Health systems comprise six building blocks: service delivery; medical products, vaccines and technologies; health workforce; health systems financing; health information system; and leadership and governance. Public-private mix (PPM) approaches or partnerships consist of initiatives aimed at increasing collaboration and improving the relationships between public-public, public-private and private-private health providers. An important component of PPM is the clear distribution of tasks between the different providers involved in the provision of health care. In practice, most PPM initiatives are disease-specific and are often related to the health service delivery block mentioned above. Although there is widespread consensus that PPM initiatives are typically of an HSS nature, efforts to make explicit the links between PPM and health systems building blocks are rather uncommon. The present paper aims to identify - in order to facilitate operationalization - potential aspects linking PPM to health systems building blocks, using a few experiences from tuberculosis control and beyond. The paper targets policymakers, donors and health systems scientists and ends with a call for more aware and innovative leadership, for increased support of PPM initiatives covering various building blocks, and for more operational research.

Diagnostic delay amongst tuberculosis patients in Jogjakarta Province, Indonesia is related to the quality of services in DOTS facilities

OBJECTIVES

To understand determinants of care-seeking patterns and diagnostic delay amongst tuberculosis (TB) patients diagnosed at direct observed treatment short course (DOTS) facilities in Jogjakarta, Indonesia.

METHODS

Cross-sectional survey amongst newly diagnosed TB patients in 89 DOTS facilities whose history of care-seeking was reconstructed through retrospective interviews gathering data on socio-demographic determinants, onset of TB symptoms, type of health facilities visited, duration of each care-seeking action were recorded.

RESULTS

Two hundred and fifty-three TB patients were included in the study whose median duration of patients' delay was 1 week and whose total duration of diagnostic delay was 5.4 weeks. The median number of visits was 4. Many of the patients' socio-demographic determinants were not associated with the care-seeking patterns, and no socio-demographic determinants were associated with the duration of diagnostic delay. More than 60% of TB patients started their care-seeking processes outside DOTS facilities, but the number of visits in DOTS facilities was greater during the overall care-seeking process. Surprisingly, patient's immediate visits to a DOTS facility did not correspond to shorter diagnostic delay.

CONCLUSION

Diagnostic delay in Jogjakarta province was not associated with patients' socio demographic factors, but rather with the health system providing DOTS services. This suggests that strengthening the health system and improving diagnostic quality within DOTS services is now a more rational strategy than expanding the TB programme to engage more providers.

Private practitioners and tuberculosis case detection in Jogjakarta, Indonesia: actual role and potential

BACKGROUND

Indonesia has a high tuberculosis (TB) prevalence and a large private health sector.

OBJECTIVES

To explore the potential of private practitioners (PP) in TB control in Jogjakarta by assessing their load of TB suspects and case-management practices.

METHODS

We conducted a cross-sectional telephone survey of a random sample of 164 PP, weighted to the local proportions of specialists, general practitioners (GP), nurses and midwives. We investigated their knowledge of directly observed treatment, short-course (DOTS), whether they see TB suspects, whether they refer such patients and how they possibly diagnose and treat TB.

RESULTS

We sampled 174 PP, of which 164 (94.3%) completed the interview. Most PP (63.4%) reported to have seen TB suspects in their private practice, and 62.8% were also employed in a DOTS facility. Specialists saw on average 18 suspects, GP 11 suspects, and nurses-midwives three suspects in a year. Many PP (45.2%) always relied on National Tuberculosis Control Programme (NTP) services for diagnosis. Fewer PP (41.5%) used, by themselves, diagnostic procedures complying with the NTP guidelines. The majority (63.6%) always referred confirmed cases for treatment, mainly (71.4%) to NTP services. Most PP (72.7%) who treated TB patients themselves did not prescribe the NTP standard regimen.

CONCLUSION

The study shows that the TB case load per PP is low in Jogjakarta, where the NTP already involves public and private hospitals besides public health centres. Initiatives to engage all PP might only marginally contribute in increasing the TB case detection.

Can malaria be controlled where basic health services are not used?

OBJECTIVE

To assess the potential of integrating malaria control interventions in underused health services.

METHODS

Using the Piot predictive model, we estimated malaria cure rates by deriving parameters influencing treatment at home and in health facilities from the best-performing African malaria programmes and applying them to Yanfolila district, Mali.

RESULTS

Without any malaria control intervention, the population cure rate is 8.4% with home treatment, but would be 13% if access to timely treatment were improved (as in Kenya). A further 3.2% of malaria patients could be cured in institutional settings with more sensitive diagnosis, timely start of treatment, better compliance (as in Uganda, Tanzania, Ghana) and 80% chloroquine efficacy. Applied in a setting where 7.6% of malaria patients seek institutional care, these assumptions would result in a total population cure rate of 14.5%. Increasing the health service user rate from 0.17 in Yanfolila to 0.95 new cases/inhabitant/year (as in Namibia) would result in half of all malaria patients attending professional services, raising the cure rate to 26.1%.

CONCLUSION

If malaria patients are to be treated and followed-up early and appropriately, basic health services need to deliver integrated care and be attended by an adequate pool of users. Improved service user rates and case management can increase malaria cure rates far more than isolated control interventions can. This has implications for international policies endorsing a narrow disease-based approach.