Large funding inflows, limited local capacity and emerging disease control priorities: a situational assessment of tuberculosis control in Myanmar

Progress of South East Asian Region countries towards achieving interim End TB strategy targets for TB incidence and mortality: a modelling study

OBJECTIVES

In 2018, the World Health Organisation (WHO) reported that almost 10 million people worldwide had tuberculosis (TB). The majority of the TB cases were concentrated in South East Asian Region (SEAR) countries. To curb this burden, the WHO has set interim targets to reduce TB incidence by 50% and mortality by 75% by 2025 (interim targets of the 'End TB' strategy). Hence, this study was conducted to determine the progress of SEAR countries towards reaching these interim targets for TB incidence and mortality.

METHODS

Secondary data analysis was performed using information from the WHO Global Health Observatory and Global Health Estimates for all SEAR countries. ARIMA modelling was used to forecast TB incidence and TB mortality from 2000 to 2025. Joinpoint regression was performed to determine the average annual percent change.

RESULTS

Based on the current trend, we estimated that the incidence and mortality of TB in SEAR countries will decline to 3.7 million (4.37 million in 2018) and 495,280 (650,979 in 2016) by 2025, respectively. Projected age-standardised TB incidence showed a significant decline in only four SEAR countries, with the maximal decline in Myanmar (47.3%) followed by India (23.4%) compared with 2015 estimates. Age-standardised TB mortality showed a declining trend in six SEAR countries, with the maximum decline found in Myanmar (60.3%) followed by Thailand (39.0%).

CONCLUSIONS

Current study findings show that it is highly unlikely for most SEAR countries to achieve the WHO recommended interim End TB targets of 50% reduction in incidence and 75% reduction in mortality by 2025.

Using critical information to strengthen pandemic preparedness: the role of national public health agencies

COVID-19 has demonstrated that most countries' public health systems and capacities are insufficiently prepared to prevent a localised infectious disease outbreak from spreading. Strengthening national preparedness requires National Public Health Institutes (NPHIs), or their equivalent, to overcome practical challenges affecting timely access to, and use of, data that is critical to preparedness. Our situational analysis in collaboration with NPHIs in three countries-Ethiopia, Nigeria and Pakistan-characterises these challenges. Our findings indicate that NPHIs' role necessitates collection and analysis of data from multiple sources that do not routinely share data with public health authorities. Since initiating requests for access to new data sources can be a lengthy process, it is essential that NPHIs are routinely monitoring a broad set of priority indicators that are selected to reflect the country-specific context. NPHIs must also have the authority to be able to request rapid sharing of data from public and private sector organisations during health emergencies and to access additional human and financial resources during disease outbreaks. Finally, timely, transparent and informative communication of synthesised data from NPHIs will facilitate sustained data sharing with NPHIs from external organisations. These actions identified by our analysis will support the availability of robust information systems that allow relevant data to be collected, shared and analysed by NPHIs sufficiently rapidly to inform a timely local response to infectious disease outbreaks in the future.

High use of private providers for first healthcare seeking by drug-resistant tuberculosis patients: a cross-sectional study in Yangon, Myanmar

Background

Drug resistance is a growing challenge to tuberculosis (TB) control worldwide, but particularly salient to countries such as Myanmar, where the health system is fragmented across the public and private sector. A recent systematic review has identified a critical lack of evidence for local policymaking, particularly in relation to drivers of drug-resistance that could be the target of preventative efforts. To address this gap from a health systems perspective, our study investigates the healthcare-seeking behavior and preferences of recently diagnosed patients with drug-resistant tuberculosis (DR-TB), focusing on the use of private versus public healthcare providers.

Methods

The study was conducted in ten townships across Yangon with high DR-TB burden. Patients newly-diagnosed with DR-TB by GeneXpert were enrolled, and data on healthcare-seeking behavior and socio-economic characteristics were collected from patient records and interviews. A descriptive analysis of healthcare-seeking behavior was followed by the investigation of relationships between socio-economic factors and type of provider visited upon first feeling unwell, through univariate logistic regressions.

Results

Of 202 participants, only 8% reported first seeking care at public facilities, while 88% reported seeking care at private facilities upon first feeling unwell. Participants aged 25–34 (Odds Ratio = 0.33 [0.12–0.95]) and males (Odds Ratio = 0.39 [0.20–0.75]) were less likely to visit a private clinic or hospital than those aged 18–24 and females, respectively. In contrast, participants with higher income were more likely to utilize private providers. Prior to DR-TB diagnosis, 86% of participants took medications from private providers. After DR-TB diagnosis, only 7% of participants continued to take medications from private providers.

Conclusion

In urban Myanmar, most patients shifted to being managed exclusively in the public sector after being formally diagnosed with DR-TB. However, since the vast majority of DR-TB patients first visited private providers in the period leading to diagnosis, related issues such as unregulated quality of care, potential delays to diagnosis, and lack of care continuity may greatly influence the emergence of drug-resistance. A greater understanding of the health system and these healthcare-seeking behaviors may simultaneously strengthen TB control programmes and reduce government and out-of-pocket expenditures on the management of DR-TB.