Implementing a successful tuberculosis programme within primary care services in a conflict area using the stop TB strategy: Afghanistan case study

Reply to 'Addressing smoking cessation in tuberculosis control'.

This paper reviews the overarching strategies, implementation rigour, achievements, strengths and weaknesses, and challenges and opportunities faced by Pakistan’s National Tuberculosis Control Program (NTP) during the period 2011-2020. NTP’s annual reports, Global Tuberculosis (TB) Report (2019 & 2020), peer-reviewed journal articles, NTP and NSP plans, along with voluminous programmatic data reviewed. Pakistan’s national and provincial tuberculosis control program has treated around four million people and gained more than 90% treatment success. Iterative planning, partnership with the private sector, strategic advocacy, communication, social mobilization, operational research, and increasing domestic funding are essential to improving case notification and treatment success. Lack of adequate political commitment, over-and under-reporting, lack of a systematic mechanism for sputum transport, and inefficient coverage from the private sector are the main areas for improvement. Local and national strategic planning in funding, program development, and implementation is imperative from a multisectoral perspective for ending TB. Ensuring universal health coverage, treating drug-resistant cases, maintaining and strengthening the national health information system, and upgrading the vital registration system is the cornerstone for ending TB.

El objetivo del presente trabajo consistió en estudiar el tratamiento constitucional que se le dio a la cuestión inmigratoria en la provincia de Santa Fe durante las últimas décadas del siglo XIX, a través del debate y sanción de cuatro cuerpos constitucionales (correspondientes a 1872, 1883, 1890 y 1900). En dichas constituciones se impuso la idea fundamentada en la frase: para el extranjero, derechos civiles: todos, derechos políticos: ninguno, y las voces que sonaron, en sentido contrario, en el seno de la convención de 1900, no lograron modificar esa línea. Otro punto a destacar es la existencia de la cuestión de la nacionalidad como problema. Que la necesidad de lograr la nacionalización cultural de los inmigrantes era una cuestión central de la hora, sobre todo en el período correspondiente a las dos últimas convenciones (1890 y 1900), lo demuestra el hecho de que tanto los que abogaban por una concesión de mayores derechos a los extranjeros, como quienes defendían lo contrario, lo hacían argumentando que su respectiva posición sería la que contribuiría al logro de la homogeneización nacional. El problema se vinculaba con una cuestión eminentemente jurídica: los conceptos de ciudadanía y naturalización, qué alcances poseían éstos en el marco de la Constitución Nacional, y que encuadre debía otorgarles la provincia de Santa Fe en su legislación, discusión que tuvo lugar en el contexto de un gran debate nacional centrado en la convicción de que la naturalización del extranjero favorecería su nacionalización. El momento de mayor debilidad del status constitucional del extranjero se ubicó en la década durante la cual estuvo vigente la constitución de 1890, que privó al extranjero del derecho de voto comunal. La reforma de 1900 significó un avance con respecto a aquél que, sin embargo, no restauró la situación de la cual había gozado el extranjero gracias a las Constituciones de 1872 y 1883. El momento de mayor liberalidad constitucional, entonces, con respecto al extranjero, habría que ubicarlo al inicio del período objeto de estudio, cuando la presencia inmigratoria no era aún abrumadora. Con los años, en cambio, y ante el aumento de la proporción de extranjeros, se optó por concesiones más controladas, ya que, para la elite dirigente, el ámbito de la política debía continuar siendo patrimonio de un reducido grupo de argentinos, de aquellos que -por educación, por tradición, por familia- se sentían llamados a custodiar los principios sagrados de la nacionalidad.

DOTS implementation in a post-war, United Nations-administered territory: Lessons from Kosovo

Evaluation of primary health care service participation in the National Tuberculosis Control Program in Menofya Governorate

In theory, the removal of user fees puts health services within reach of everyone, including the very poor. When Burkina Faso adopted the DOTS strategy for the control of tuberculosis, the intention was to provide free tuberculosis care. In 2007-2008, interviews were used to collect information from 242 smear-positive patients with pulmonary tuberculosis who were enrolled in the national tuberculosis control programme in six rural districts. The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient's household. During the course of their care, three quarters of the interviewed patients apparently faced "catastrophic" health expenditure. Inadequacies in the health system and policies appeared to be responsible for nearly half of the direct costs (US$ 45 per patient). Although the households of patients developed coping strategies, these had far-reaching, adverse effects on the quality of lives of the households' members and the socioeconomic stability of the households. Each tuberculosis patient lost a median of 45 days of work as a result of the illness. For a population living on or below the poverty line, every failure in health-care delivery increases the risk of "catastrophic" health expenditure, exacerbates socioeconomic inequalities, and reduces the probability of adequate treatment and cure. In Burkina Faso, a policy of "free" care for tuberculosis patients has not met with complete success. These observations should help define post-2015 global strategies for tuberculosis care, prevention and control.

ObjectiveTo understand how national and provincial tuberculosis programme managers in Pakistan perceive and engage with the Stop TB strategy, its strengths, weaknesses and their experience in its implementation. National and provincial tuberculosis programme managers play an important role in effective implementation of the Stop TB strategy.DesignA qualitative interview study was conducted with 10 national and provincial tuberculosis programme managers to understand how they perceive and engage with the Stop TB strategy, its strengths, weaknesses and their experience in its implementation. Managers were selected purposively; 10 managers were interviewed (six national staff and four from provincial level).ParticipantsNational and provincial tuberculosis programme managers in Pakistan. Managers were selected purposively; 10 managers were interviewed (six national staff and four from provincial level).SettingNational and provincial tuberculosis programmes in PakistanMain outcome measures1. Knowledge and perceptions of national and provincial tuberculosis programme managers about the Stop TB strategy 2. Progress in implementing the strategy in Pakistan 3. Significant success factors 4. Significant implementation challenges 5. Lessons learnt to scale up successful implementation.ResultsThe managers reported that most progress had been made in extending DOTS, health systems strengthening, public -private mixed interventions, MDR-TB care and TB/HIV care. The four factors that contributed significantly to progress were the availability of DOTS services, the public-private partnership approach, comprehensive guidance for TB control and government and donor commitment to TB control.ConclusionThis study identified three main challenges as perceived by national and provincial tuberculosis programme managers in terms of implementing the Stop TB strategy: 1. Inadequate political commitment, 2. Issue pertaining to prioritisation of certain components in the TB strategy over others due to external influences and 3. Limitations in the overall health system. To improve the tuberculosis control programme in the country political commitment needs to be enhanced and public -private partnerships increased. This can be done through government prioritisation of TB control at both national and provincial levels; donor-funded components should not receive undue attention; and partnerships with the private health sector, health institutions not yet covered by DOTS services, non-governmental organisations and patient coalitions should be increased.

BackgroundGlobally, there has been growing evidence that suggests the effectiveness of active case finding (ACF) for tuberculosis (TB) in high-risk populations. However, the evidence is still insufficient as to whether ACF increases case notification beyond what is reported in the routine passive case finding (PCF). In Cambodia, National TB Control Programme has conducted nationwide ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts alongside routine PCF. This study aims to investigate the impact of ACF on case notifications during and after the intervention period.MethodsUsing a quasi-experimental cluster randomized design with intervention and control arms, we compared TB case notification during the one-year intervention period with historical baseline cases and trend-adjusted expected cases, and estimated additional cases notified during the intervention period (separately for Year 1 and Year 2 implementation). The proportion of change in case notification was compared between intervention and control districts for Year 1. The quarterly case notification data from all intervention districts were consolidated, aligning different implementation quarters, and separately analysed to explore the additionality. The effect of the intervention on the subsequent case notification during the post-intervention period was also assessed.ResultsIn Year 1, as compared to expected cases, 1467 cases of all forms (18.5%) and 330 bacteriologically-confirmed cases (9.6%) were additionally notified in intervention districts, whereas case notification in control districts decreased by 2.4% and 2.3%, respectively. In Year 2, 2737 cases of all forms (44.3%) and 793 bacteriologically-confirmed cases (38%) were additionally notified as compared to expected cases. The proportions of increase in case notifications from baseline cases and expected cases to intervention period cases were consistently higher in intervention group than in control group. The consolidated quarterly data showed sharp rises in all forms and bacteriologically-confirmed cases notified during the intervention quarter, with 64.6% and 68.4% increases (compared to baseline cases), and 46% and 52.9% increases (compared to expected cases), respectively. A cumulative reduction of case notification for five quarters after ACF reached more than -200% of additional cases.ConclusionsThe Cambodia’s ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts resulted in the substantial increase in case notification during the intervention period and reduced subsequent case notification during the post-intervention period. The applicability of retrospective contact investigation in other high-burden settings should be explored.

Is the Australian primary healthcare system ready for the Rheumatic Heart Disease Endgame strategy? Data synthesis and recommendations

There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and as DM increases the risk of TB and adversely affects TB treatment outcomes, there is a need for bidirectional screening of the two diseases. How this is best performed is not well determined. In this pilot project in China, we aimed to assess the feasibility and results of screening DM patients for TB within the routine healthcare setting of five DM clinics. Agreement on how to screen, monitor and record was reached in May 2011 at a national stakeholders meeting, and training was carried out for staff in the five clinics in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. DM patients were screened for TB at each clinic attendance using a symptom-based enquiry, and those positive to any symptom were referred for TB investigations. In the three quarters, 72% of 3174 patients, 79% of 7196 patients and 68% of 4972 patients were recorded as having been screened for TB, resulting in 7 patients found who were already known to have TB, 92 with a positive TB symptom screen and 48 of these newly diagnosed with TB as a result of referral and investigation. All patients except one were started on anti-TB treatment. TB case notification rates in screened DM patients were several times higher than those of the general population, were highest for the five sites combined in the final quarter (774/100 000) and were highest in one of the five clinics in the final quarter (804/100 000) where there was intensive in-house training, special assignment of staff for screening and colocation of services. This pilot project shows that it is feasible to carry out screening of DM patients for TB resulting in high detection rates of TB. This has major public health and patient-related implications.

India initiated National Tuberculosis Control Program (NTCP) in 1962. After reviewing NTCP and realizing its shortcomings, the Government of India evolved and adopted a revised strategy - the directly observed treatment short course (DOTS) - under Revised National Tuberculosis Control Program (RNTCP) with the goal of reducing TB burden and the twin objective of 70% case detection and 85% cure rates. RNTCP was launched in 1993, in a phased manner to be evolved through pilot phase (1993-1996), DOTS intensification phase (1997-2006), Stop TB strategy (2007-2011), and currently the Universal Access or National Strategic Plan (2012-2017). RNTCP has been progressing successfully toward its goal and achieving its objectives since 2007. This addresses the Millennium Development Goal (MDG) and target to be achieved by 2015 and the Stop TB Partnership targets to be achieved by 2015 and by 2050. By 2011, the RNTCP has treated more than 14.2 million TB patients and saved 2.6 million additional lives using the DOTS strategy. The spread of human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS), emergence of multidrug resistant TB (MDR-TB) and the unregulated and underutilized vast private sector using anti-TB regimes different from those under RNTCP pose additional challenges in the control of tuberculosis.<br>For this review, information has been collected from official websites of World Health Organisation (WHO) Geneva, WHO South East Asia Regional Office (SEARO) New Delhi, Ministry of Health and Family Welfare; Government of India and published literature, through search engines like Google, Google Scholar and Pub Med using MeSH Terms DOTS and Tuberculosis Control.

Introduction: Pakistan ranks fifth in the globally estimated burden of tuberculosis (TB) case incidence. Annually, a gap of 241,688 patients with TB exists between estimated TB incidence and actual TB case notification in Pakistan. These undetected/missed TB cases initiate TB care from providers in the private healthcare system who are less motivated to notify patients to the national database that leads to significant underdetection of actual TB cases in the Pakistani community. To engage these private providers in reaching out to missing TB cases, a national implementation trial of the Public–Private Mix (PPM) model was cohesively launched by National TB Control Program (NTP) Pakistan in 2014. The study aims to assess the implementation, contribution, and relative treatment outcomes of cohesively implemented PPM model in comparison to the non-PPM model.Methods: A retrospective record review of all forms (new and relapse) patients with TB notified from July 2015 to June 2016 was conducted both for PPM- and non-PPM models.Results: The PPM model was implemented in 92 districts in total through four different approaches and contributed 25% (81,016 TB cases) to the national TB case notification. The PPM and non-PPM case notification showed a strong statistical difference in proportions among compared variables related to gender (p < 0.001), age group (p < 0.000), and province (p < 0.000). Among PPM approaches, general practitioners and non-governmental-organization facilities achieve a treatment success of 94–95%; private hospitals achieve 82% success, whereas Parastatals are unable to follow more than half of their notified TB cases.Discussion: The PPM model findings in Pakistan are considerably consistent with countries that have prioritized PPM for an increasing trend in the TB case notification to their national TB control programs. Different PPM approaches need to be scaled up in terms of PPM implemented districts, PPM coverage, PPM coverage efficiency, and PPM coverage outcome in the Pakistani healthcare system in the future.

The overall aim of this thesis was to understand how new policies are reflected in national policy, and subsequently implemented. It suggests a fruitful way of analysing how policies fare is through exploring the notion of policy transfer - a complex process, mediated by different groups of actors. The focus for this study was on one particular policy: that of integrating management of HIV and sexually transmitted diseases (STD) with primary health care (PHC) services. During the 1990s, after clinical trials showing that HIV transmission could be slowed if STDs were controlled at the PHC level, the international community strongly promoted the idea that management of HIV and STDs should be integrated into PHC services. This thesis explores the trajectory of this impetus: from policy development at international level, to the response at national level. It suggests that integration of these services was driven by strong leadership from women's groups and international donors. New technologies, such as syndromic management of STDs, were perceived to be one of the ways in which integration could be introduced at the primary level. However, reviewing such experience that exists, shows that the enthusiasm for integration of HIV/STDs with PHC services was soon tempered as limited political, financial and technical resources hindered effective implementation. The study argues that limited political interest in integration was due partly to the fact that some countries were characterised by a relatively coercive relationship between external funders and national policy makers. This meant that efforts to introduce policy reforms were not strongly supported by governments, through allocation of financial or other resources, and donors were forced to spend according to their own priorities. Thus while there was agreement at national levels to policies, in fact, at sub-national levels implementation was weak. The thesis then goes on to explore South Africa's experience, which provides a contrast to the experience of many other African countries. Relatively isolated from international discourse until the early to mid 1990s, South Africa developed its own policies on integration, reflecting many of the same concerns and interests of the international community, but generating such concern from within the country, rather than having it imposed from outside. The thesis analyses developments in policy in the country, from agenda setting to policy formulation, and then looks at what happened during implementation in the Northern Province, one of the poorest parts of South Africa, and more akin to its northern neighbours than other areas. It shows that policies were developed in a context of radical and rapid political and economic change and, as a result, national policy makers sometimes failed to take account of impediments to implementation at sub-national levels, or of the constraints to service delivery. The thesis concludes by expanding on an analytical framework for policy which incorporates the notion of policy transfer, as a necessary adjunct to understanding how policies are formulated and implemented. It suggests that where international agendas are not reflected in national policy discourse, they are less likely to be fully absorbed or implemented. However, even where policies are transferred between national and sub-national levels, problems remain with implementation which need to be addressed.

Objective: World Health Organization (WHO) identified a gap in meeting mental health care needs in the health services. To bridge this gap, at Yarmouk Primary Health Care Center and Capital Health District area in Kuwait, it was decided to implement a best practice model, for integrating mental health services into primary health care services in Kuwait. Methodology: Implementation of the best practice model, for integrating mental health services into primary care services in Kuwait’s health system was initiated in 2008. It involved the integration of cost–effective, feasible evidence-based interventions for mental health conditions in Primary Health Care (PHC) and other priority health programs. It envisioned a mental health component in PHC, to enhance access to mental health care and improve identification and treatment rates for priority mental disorders, to provide holistic care for particularly disabling comorbid physical and mental health problems, and to engage in mental health promotion. Results: The program was initiated in 12 primary mental health care clinics in the Capital Health District area in Kuwait. Two hundred (200) Family Physicians and General Practitioners, were trained in psychiatric integration within the primary health care system. Regular evaluation of the performance of physicians working in primary mental health clinics in the program was ensured. Periodic evaluation of psychiatric patient visits in the Primary mental health clinics was conducted for quality improvement. Mental health awareness days and educational sessions were organized. Discussion: A practice model for integrating mental health services into primary care was developed in Kuwait, involving stakeholders. Its favorable impact on mental health in the community is undergoing scrutiny. Limitations such as human resource shortage and, movement of trained physicians from primary care to other administrative departments in the Ministry of Health (MOH), coupled with a lack of relevant data and the need for better coordination between stakeholders, were identified. Issues regarding electronic health records, patient confidentiality, and quality of services were identified. Stigma related to mental health issues resulted in a delay in implementing the integration. Conclusion: With increasing psychiatric illnesses and a lack of adequate specialized mental health services, addressing this issue at the primary care level offers an attractive cost-effective option to deal with the crisis. Keywords: Mental Health, Primary Health Care, Integration, Health system, Family Physician

ntroduction: Tuberculosis is globally one of the ten biggest causes of death in the world, around 10.6 million new cases and 1.3 million deaths in 2022. Indonesia ranks second in the world in the list of countries with a high tuberculosis burden. There are 19,071 cases of tuberculosis sufferers in South Sulawesi. Makassar City ranks first, namely 9,157 cases of tuberculosis found throughout 2023. The purpose of the study was to emphasize its dual focus on assessing political commitment and policy opportunities. Method: The research design used is quasi-qualitative research and the Mayor of Makassar is the key informant. The data collection technique uses the PCOM-RAT (Political Commitment and Opportunity Measurement-Rapid Assessment Test) survey questionnaire and is continued with in-depth interviews with informants. Result: Measurement of political commitment using the PCOM-RAT questionnaire is divided into three parts, namely verbal commitment, institutional commitment, and budget commitment. The assessment score for the political commitment of the Mayor of Makassar shows good political commitment, with a total political commitment score of 18. Opportunities for developing TB policies can be understood based on three streams, namely problem stream, policy stream, and political stream. The overall assessment score shows that Makassar City has had a high opportunity for developing TB policies, with a total score of 29. Conclusion: The Mayor of Makassar has a high political commitment in the TB elimination policy in Makassar City. High political commitment from a Regional Head is an opportunity for the success of implementing a program. Political commitment is the desire to act and continue to act until the job is done. A leader who has a high political commitment to tuberculosis will resolve the tuberculosis problem until it is finished. Furthermore, the opportunity to develop a TB elimination policy in Makassar City is also high. The TB elimination policy can be developed by paying attention to increasing the capacity of health workers in case finding, improving the quality of TB screening and diagnosis, improving the treatment monitoring system, encouraging community participation by strengthening collaboration between stakeholders, and also encouraging research to improve TB control capabilities.