2009 TB Control and Health Systems: Connect the dots (brochure)

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Message from the Regional Director

TIME TO ACT! How can National TB Programmes help strengthen health systems? A first step is to strengthen links with the Ministry of Health (particularly planning and policy departments), professional organizations and any relevant bodies. They can work proactively with them to identify problems and resource needs, develop policy, implement solutions, assess costs and mobilize resources through national and local frameworks. Other action points include:

In 1999, following a 40% rise in TB cases over six years, the World Health Organization declared a “tuberculosis crisis” in the Western Pacific.

Governments responded with an accelerated expansion of DOTS, the WHO-recommended TB control strategy.

Leadership & Governance ?

SET STANDARDS,

if needed by law, on TB case management (for notification, referral, free treatment, adoption of DOTS).

HOSPITAL

Despite these gains, a long road lies ahead. Every day, 5000 people newly develop TB in the Region, while multidrug-resistant TB (MDR-TB) and the TB-HIV co-infection are growing threats.

Financing ?

PROVIDE

FREE TB SERVICES through financing mechanisms (to cover staff, drugs and equipment), incentives and compensation of service providers.

Our available tools work, but they are not enough. To progress, we must think bigger and look beyond DOTS to the actual setting in which TB programmes operate — national health systems. We must connect the dots from the branches of TB programmes to their roots within health systems.

Human Resources ?

SUSTAIN

STAFF who are skilled, trained and well-distributed by identifying needs and sharing resources, offering fitting salaries and perks, and providing supportive training and supervision.

Currently, effective TB control is constrained by health system weaknesses: chronic staff shortages, low access to quality care; and poor links between service providers. The resource gaps and inequity in TB care are often huge.

Information INFORMATION to identify weaknesses and strengths through regular data collection and analysis while also simplifying data gathering.

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GATHER

Medical Products

Ten years later, TB control is stronger than ever in the Western Pacific Region. DOTS can be found even in the most remote areas. Case detection has soared to 78%, and more than 90% of cases are successfully treated.

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Consider MDR-TB. How can we tackle it when most laboratories lack sufficient numbers of skilled technicians and even the tools to identify cases? The risk of an uncontrolled MDR-TB epidemic compels us to take action.

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BUILD

DRUG MANAGEMENT systems for optimum procurement, supply, distribution and cost saving, while also promoting rational drug use. ?

IMPROVE LABORATORY CAPACITY by maximising or sharing resources and regularly maintaining equipment.

Ongoing health sector reforms may well affect how TB control is planned and delivered. They also offer opportunities. The time to act is now.

To begin with, governments must ensure TB treatment is entirely free of charge. So often, patients must pay for needless extras. For the sake of global health, governments must take on this responsibility.

Service Delivery ENGAGE ALL SERVICE PROVIDERS in TB control through expanding DOTS and referral systems, and optimising use of resources with good management. ?

ASSURING QUALITY by extending initiatives to all facilities, for all aspects of delivery, and by promoting accreditation systems and external quality assurance.

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Financial mechanisms are needed to support this, such as subsidies for facilities diagnosing and treating TB. Increasing coverage of health insurance will alleviate costs for the poor, who often pay huge out-ofpocket fees.

TB CONTROL AND HEALTH SYSTEMS

Connect the d ts World TB Day, 24 March 2009

Engaging all care providers is also critical. The private sector and hospitals, both public and private, remain the weakest link in the chain of TB control.

We need to connect the dots between them and TB programmes.

Collaboration is critical.

Health systems must respond to the needs of TB control. In doing so, the benefits — better laboratory infrastructure, skilled staff, quality service delivery and equitable access to services — improve both health systems and TB control.

Delivering TB care through strong health systems has far-reaching rewards, even contributing towards poverty alleviation. Ultimately, investments in health become investments in national development. It is time to think big and take a holistic, systems approach to TB care. We need to stretch our vision, from programme to system. TB and health systems – let’s connect the dots!

WHO Regional Office for the Western Pacific • http://stoptb.wpro.who.int Photos: WHO/WPRO Image Bank | Pierre Virot | TDR Image Library

WHO / WPRO

Stopping TB

http://stoptb.wpro.who.int

Shin Young-soo, MD, Ph.D. WHO Regional Director for the Western Pacific

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Delivering TB care through strong health systems

Patients paying for “free” TB services Health spending remains low in many Asia Pacific countries, despite rising costs of care. Cambodia, China, the Philippines and Viet Nam spend less than 2% of their gross domestic product on health — below the recommended figure of 5%.

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With public financing at low levels, unregulated commercialisation has escalated — even in the public sector.

User fees are common. “Free” TB treatments often come with additional items, such as x-rays or “liver-protection drugs” that can be costly enough to force patients to drop treatment.

In many countries, TB dispensaries and hospitals must cover operational costs with user fees. To raise revenue, staff tend to prescribe and sell more medicines and services. This has led to irrational prescribing in many instances.

Patients often pay health care fees out of their own pockets. This is the case for more than half of all health spending in Cambodia, China, the Philippines and Viet Nam. Out-of-pocket payments create an extremely inequitable system, deterring patients from seeking care. Even modest fees can lead to catastrophic costs if services are frequently used, driving patients to destitution.

User fees for TB services must be abolished. To ensure equity, resources can be raised through prepayments — taxes, insurance or social security. TB subsidies and capitation (fixed prepaid funding per per patient) can help address financing issues.

Governments must sustain TB control without the poor having to contribute to financing services. “Free” TB treatment must be kept truly free.

When Feng Ming Gui became ill with tuberculosis (TB), he spent US$ 240 on futile treatment: penicillin and glucose.

Feng and his wife, who began making his burial clothes fearing he would die, sold everything they owned seeking a cure.

Feng, from a village in Jiangsu province, China, was fortunate - he finally did get a diagnosis of TB.

In these countries, health systems are often cash-strapped, with basic services and infrastructure. Resources are often used inequitably and inefficiently, with funds skewed to tertiary hospitals rather than public health. Rural services are woefully short staffed. Unregulated commercialism, even in public services, has made high user fees the norm.

Feng’s story is typical in countries with a high TB burden: inadequate diagnosis and treatment; poor access to quality care and high user fees causing financial catastrophe — in short, health systems that fail to deliver.

In such settings, even the best of TB programmes can only achieve limited success. DOTS, WHO’s recommended TB control strategy, is a powerful weapon in the battle against TB. But we need to also look at how various components of the

health system impact it. We need to connect the "dots" from healthems to DOTS. The need to strengthen health systems for TB control is especially urgent in the wake of multidrug-resistant TB. Many affected countries simply do not have the necessary staff, finances or laboratory capacity to deal with it.

With many countries undertaking health care reforms, this is an opportune time to strengthen health systems and epidemic response. Within the challenge lies an opportunity for TB programmes.

The reasons for the inadequate quantity, quality, mix and distribution of health workers are complex, but foremost is the lack of attention to the issue. Many workers are leaving for jobs in the private sector or overseas. Also, the health workforce tends to be concentrated in urban rather than rural areas.

Recruiting staff, including nurses and even physicians, is especially challenging for TB, with the associated risk of infection and stigma. The problem is most acute for laboratories dealing with multidrug-resistant TB (MDR-TB), where biosafety levels are often inadequate.

Governments must improve overall human resources planning and management, at the national and programme level. There must be strategies to recruit, train, retain and motivate staff — which could involve wages, promotion or training — as well as mechanisms to mobilize resources for these strategies.

Supervision, support and morale-building can help boost performance.

Incentives, such as a “risk allowance”, can attract staff to TB services. In large hospital laboratories, technicians could rotate to work in other services.

Training is a key issue for laboratory staff, particularly with the greater demand for skills to tackle MDR- TB. Career opportunities must be considered for laboratory managers and other staff.

Collaboration with other public providers and institutions, including secondments, can secure more staff. Some TB programmes are using such innovative strategies.

Governments must realize that people are the engine of health systems. A skilled and motivated workforce is vital to steer TB control in the right direction.

means the necessary funding, regulation, human resources and tools. Then people like Feng can get diagnosed early and treated appropriately without getting bankrupt first.

"I never thought he'd be cured.

I made his burial clothes."

–Wei Hua, wife of TB patient Feng Ming Gui

Governments must ensure that TB control gets support from health systems, which

Quality TB care lacking in hospitals and private sector

Workforce crisis threatens TB control progress The crisis in human resources is perhaps the greatest challenge facing TB control and health systems. In many countries, it is not only a funding issue but also the shortage of skilled staff that constrains scaling up TB services.

Innovative methods to overcome barriers, such as engaging the private sector to implement DOTS, are slowly being adopted. But far more must be done.

Incentives are necessary to attract staff to TB services. Financial mechanisms are needed to ensure health facilities keep treatment free rather than earn income from patients. Quality initiatives and laboratory capacity must be expanded.

These measures will, in turn, strengthen systems.

HOSPITAL

For most TB patients, the first point of care is not a TB health facility offering free treatment but a more accessible hospital outpatient department or private clinic. Patients may also believe they will get better care there.

Usually operating outside the national TB programme, many of these facilities charge hefty fees for TB services . One study found up to 30% of TB patients had to make more than six visits to a health facility before diagnosis. Misdiagnoses are not uncommon. If a patient is finally diagnosed with TB, treatment in these facilities is frequently substandard.

If profits are maximized by offering services, there is a financial disincentive in referring patients to free TB clinics. Excessive investigations — x-rays, culture and blood tests — are commonly done, delaying diagnosis. With costs spiralling from tests, drugs, transportation, and time taken off work, the patient may be forced to stop treatment. Hospitals usually fail to follow up such cases.

This pool of infectious TB patients, who suffer delayed, inadequate or even incorrect, diagnoses and treatment, is a chief source of the “missing” cases invisible to TB programmes. Substandard TB services also raise the threat of multidrug-resistant TB. All health facilities offering TB care — national or peripheral hospitals, the private sector or even prisons — must support TB control objectives. The DOTS strategy must be extended to the Region’s large and growing private sector. Referrals to TB clinics should be encouraged.

We need to “connect the dots” between all health care providers so no TB patient goes “missing” and without care. The Public-Private Mix (PPM) approach aims to do that, by involving the private sector and hospitals in quality TB care.

It is imperative that governments take further action for a wider health system engagement involving hospitals and private providers so that free, quality TB services are available to all TB patients.

WHO/TBP/Colors Magazine/J. Mollison

Connecting the dots:

Quality lacking in service delivery Improving the quality of delivery systems for TB services is a major challenge for the Region. Inferior quality of services can lead to poor health outcomes and underutilization of services. Quality Assurance (QA) programmes must be in place to ensure standards.

Quality TB care means patients do not have to make several visits to health facilities before a diagnosis is made. It also means test results are accurate and drugs are provided without interruption. All obstacles affecting the continuum of care at any stage — be it long waits or inconvenient hours — must be addressed. Innovative approaches are needed.

QA looks at clinical standards, client (patient) satisfaction and performance management. A client focus encourages staff to be respectful to patients. Performance indicators, such as case notification rates, help identify system weaknesses, not just those specific to TB. QA entails regular monitoring and supervision, accreditation, and checks by external bodies. This is best done systematically for the general health service, rather than as fragmented programmes for TB control. However, most quality initiatives remain limited; few are national in scale.

For real change, QA has to be system-wide, driven from top and bottom. Quality must become part of the overall health service culture to achieve quality improvements.

It is imperative that governments take further action for a wider health system engagement involving hospitals and private providers so that free, quality TB services are available to all TB patients.