The Global Fund in China: Multidrug-resistant tuberculosis nationwide programmatic scale-up and challenges to transition to full country ownership.

Lixia Wang,Yuhong Liu,Liang Li,Yunzhou Ruan,Hui Zhang,Yanlin Zhao,Yu Wang,Dongmei Wang,Emilio Dirlikov,Fabio Scano,Xin Du,Bernhard Schwartländer,Renzhong Li,Dennis Falzon,Ming-Ting Chen ,Jian Zhao ,Yiyuan Sun ,Sheng Fen Wang ,Cheng Xu

doi:10.1371/journal.pone.0177536

Abstract

China has the world’s second largest burden of multidrug-resistant tuberculosis (MDR-TB; resistance to at least isoniazid and rifampicin), with an estimated 57,000 cases (range, 48,000–67,000) among notified pulmonary TB patients in 2015. During October 1, 2006–June 30, 2014, China expanded MDR-TB care through a partnership with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). We analyzed data on site expansion, patient enrolment, treatment outcomes, cost per patient, and overall programme expenditure. China expanded MDR-TB diagnostic and treatment services from 2 prefectures in 2006 to 92 prefectures, covering 921 of the country’s 3,000 counties by June 2014. A total of 130,910 patients were tested for MDR-TB, resulting in 13,744 laboratory-confirmed cases, and 9,183 patients started on MDR-TB treatment. Treatment success was 48.4% (2011 cohort). The partnership between China and the Global Fund resulted in enormous gains. However, changes to health system TB delivery and financing coincided with the completion of the Global Fund Programme, and could potentially impact TB and MDR-TB control. Transition to full country financial ownership is proving difficult, with a decline in enrollment and insufficient financial coverage. Given needed improvement to the current treatment success rates, these factors jeopardise investments made for MDR-TB control and care. China now has a chance to cement its status in TB control by strengthening future financing and ensuring ongoing commitment to quality service delivery.

Highlights

IntroductionIn 2015 there were an estimated 580,000 (range, 520,000–640,000) new cases of multidrugresistant, defined as resistance to at least isoniazid and rifampicin, or rifampicin-resistant TB (MDR/RR–TB) [1]
Drug resistant forms of tuberculosis (TB) pose a serious threat to control efforts
We review China’s multidrug-resistant tuberculosis (MDR-TB) scale-up initiated in collaboration with the Global Fund, from October 2006 to June 2014 inclusive

Summary

Introduction

In 2015 there were an estimated 580,000 (range, 520,000–640,000) new cases of multidrugresistant, defined as resistance to at least isoniazid and rifampicin, or rifampicin-resistant TB (MDR/RR–TB) [1]. Drug-resistance among TB patients varies geographically, with the highest reported proportions occurring in Eastern Europe and Central Asia, while India and China are estimated to have the first and second largest burdens of MDR-TB respectively [1,2]. In 2007, China conducted its first national TB drug-resistance survey, finding that 5.7% (range, 4.5–7.0%) of new and 25.6% (range, 21.5–29.8%) of retreatment TB patients were MDR-TB [3]. Of 9,662 laboratory-confirmed patients with MDR/RR-TB, 5,691 (59%) were started on treatment; of 357 laboratory-confirmed patients with extensively drug-resistant TB (XDR-TB), defined as MDR-TB plus additional resistance to a fluoroquinolone and a second-line injectable, 122 (34%) patients were started on treatment [1]

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Results

Conclusion