A BRIEF HISTORY AND ANALYSIS OF PAKISTAN’S TB CONTROL MECHANISMS
By
Dr Ghulam Nabi Kazi
As the world braces itself for the fallout of a serious pandemic of COVID-19, we must nevertheless not lose sight of another serious killer –Tuberculosis - that devours 4,500 people daily from around the world, nor the suffering TB patients who are at a much greater risk of contracting COVID-19.
Pakistan was initially slow in responding to the World Health Organization declaration of Tuberculosis as a global emergency in 1993. The Government of Sindh was the first to draw up a concrete 3-year plan from 2000-2003 based on the TB-Directly Observed Treatment Short Course (DOTS) methodology. The Federal Government and other provinces followed suit in 2001 and on World TB Day on March 24, 2001 the Ministry of Health led by Minister H. E. Dr Abdul Malik Kasi and Secretary H. E. Mr. Ejaz Rahim declared TB as a national emergency and issued the Islamabad Declaration, in the context of Pakistan.
The Islamabad Declaration was initially met with a great response from governmental agencies and the health development partners including robust technical support from the Word Health Organization, social mobilization from the Stop TB Partnership and financing support from the United States Agency for International Development (USAID), British Department for International Development (DFID), Family Health International (FHI), German Leprosy and Relief Association (GLRA), German Development Bank (KfW), German Technical Cooperation (GTZ), Japan Anti-Tuberculosis Association/Research Institute for Tuberculosis (JATA/RIT), Japanese International Cooperation Agency (JICA), Royal Netherlands Association for the Prevention of Tuberculosis (KNCV Tuberculosis Foundation) and the International Union Against Tuberculosis and Lung Disease (The Union). These agencies also took part in WHO-led reviews and their joint recommendations guided the follow-up action at the relevant operational level. The core elements of the National and Provincial Tuberculosis Control Programs were financed by the government. Subsequently, the major donors routed all their grants for Tuberculosis through the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).
By 2005, the diagnostic and treatment facilities were established in all eligible public sector health facilities and were offered free of cost along with a significant amount of social mobilization. In April 2004, the WHO Inter-Country meeting of National Tuberculosis Control Program Managers was held in Lahore, indicating that Pakistan had come a long way. That was the finest hour of TB Control in Pakistan. Things had fallen into place, the facilities were strengthened, enhanced and expanded through public-private mix along with a remarkable show of commitment, dedication and a camaraderie of all stakeholders working towards a common cause just like family members.
Thereafter the program developed with greater facilities including the rampant use of GeneXpert – a molecular test for TB reducing the reliance on sputum smear microscopy by a great deal. Mobile Cad4TB Vans equipped with software that can automatically analyze chest radiographs for signs of tuberculosis. The latest technology provided by the Stop TB Partnership is in the Fuji-Xair technology, a hand held device armed with artificial intelligence, will be used for active case finding in coal miners and their associated communities in several parts of Pakistan.
The National Tuberculosis Program of Pakistan being nearly 19-20 years old is quite mature now and remains one of the country’s best performing programs. It would, however, be wrong to assume that everything is hunky-dory.
Let us try and analyze the results:
1.First and foremost, out of the estimated 560,000 cases in Pakistan around 200,000 cases are missed annually and are not being notified in the national or provincial programs. What is happening to these ‘missing’ patients is purely a matter of conjecture. It is possible those cases may be visiting private practitioners and hopefully getting cured but there is also the possibility that they are not getting any treatment at all or approaching quacks, faith healers or erroneously prescribing doctors making them TB carriers for life and spreading the disease to their contacts.
2.The last National TB prevalence survey – a colossal undertaking – left us with an incidence of 265 per 100,000 population. While there is a clamour from the provinces for a fresh prevalence survey, it appears to be an exercise in futility, while incurring a lot of expenditure as no change may have occurred in the intervening period since the last survey.
3.The overwhelming fact is that with a case notification rate of 65-70%, Pakistan has failed to make a dent in the incidence or prevalence and with the same level of effort, no significant change is likely. Thus while we may consider this effort as ‘controlling’ TB, any talk of elimination is a far cry at the moment and will require increasing the pace of effort manifold if the international commitments are to be honored.
4.By paying for only 3% of the estimated costs of the National Strategic Plan and with 31% of the costs being borne by international donors (read the Global Fund), Pakistan has not only 66% of its NSP go unfunded but has also allowed the program to be controlled from abroad. The current situation is highly untenable because if Pakistan doesn’t assume control and authority over its TB control mechanism and delays funding some of its important elements, it can never to hope to achieve the targets either of the health system as a whole or its programmatic targets.
5.Our case detection data clearly depicts that while the program funding was largely indigenous, the case notification was improving at a great pace, however, as soon as the bulk of the funding came from the Global Fund, the growth has plateaued off and come to a halt or even reduced somewhat keeping in view the population growth rate despite massive investment. Although in the first case it can be argued that the program was expanding to all districts of the country and therefore the case detection was simultaneously growing as well, that argument doesn’t hold for the period from 2010 onwards when the whole of the country had TB diagnostic and treatment coverage including some opportunities for public-private mix.
6.The good news is that Universal Health Coverage (UHC) index of essential coverage including TB care has grown from 50% in 2000 to over 75% in 2017, lowering the proportion of the population that is yet uncovered, while social protection is also growing. However, the TB treatment coverage was estimated at 64% in 2018.
At the operational level, the program is not a major priority within the district health system. The district being the hub of all programmatic activity, it has to have a multi-sectoral accountability framework headed by the Deputy Commissioner to bring about the necessary coordination among the social sectors and economic line departments. However, the role of the communities in creating awareness and urging people with cough and other TB related symptoms to seek help is sub-optimal if not totally lacking at present. This warrants the need to enhance community participation at all levels for the smooth functioning of the program.
The World Health Organization has remained a trusted partner of the National and Provincial TB Control Programs ever since the year 2000 and they usually provide the much needed technical support from all tiers of the organization, namely headquarters, the Regional Office for the Eastern Mediterranean and the Country Office for Pakistan that is functional since 1960. The current Special Assistant to the Prime Minister for Health Dr Zafar Mirza has remained a senior WHO staff member and has reiterated his commitment on several occasions to rid Pakistan of Tuberculosis as soon as practicable.
Here there is a need to make a mention of The Stop TB Partnership is a unique international body headed by its dynamic Executive Director Dr Lucica Ditiu has been aiming for a TB-free world. Founded in 2001, the Partnership has harnessed over 1700 partners in transforming the fight against TB in over 100 countries. A cornerstone of the Partnership's mission is to ensure that every TB patient has access to effective diagnosis, treatment and cure. This necessarily entails reducing the inequitable social and economic toll of TB, by placing the emphasis on the marginalized, deprived and hard-to-reach populations in all countries of the world. In addition to Pakistan, the Partnership has been working in high burden TB countries such as Angola, Bangladesh, Brazil, China, Democratic Peoples’ Republic of Korea, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Philippines, Russian Federation, South Africa, Thailand, Tanzania, Viet Nam, Cambodia, Central African Republic, Congo, Lesotho, Liberia, Namibia, Papua New Guinea, Sierra Leone, Zambia and Zimbabwe. Through its TB-REACH initiative several projects have been launched all over Pakistan with a view to provide TB care services to marginalized populations at their doorsteps through active case finding. The Dopasi Foundation is furthering the objectives of the Stop TB Partnership in Pakistan by creating enormous awareness in the general public, using celebrities as Stop TB Ambassadors, emphasizing on the need for providing TB Care as a basic human right and carrying out a prevalence survey of TB in coalminers and their associated communities all over the country and specifically in the targeted districts in each province by screening close to 400,000 persons.
To summarize, the way forward for TB Control and Elimination in Pakistan will comprise of activities to transform the political declarations into concrete End-TB Initiatives with costed work plans, the Federal and Provincial Governments will need to significantly increase their allocations to health and specifically for eliminating the funding gap in the TB response. A federal authority for TB, AIDS and Malaria will help in robustly pursuing the federal roles of laying down the policy guidelines, providing technical strength, carry out surveillance, and liaise with international donors and health partners. Such an authority will bring about better inter provincial harmony both at policy and implementation level and carry out intra-sectoral and multi-sectoral collaboration. Demand creation for TB services needs to be brought about by a structured community engagement. We also need to enhance the capacity of Provincial TB Control Programs so that they can spearhead the TB response across Pakistan. These steps are likely to increase the government ownership and reduce dependence on external financing.
As TB-Management Units (TB-MUs) may not be able to cater to the needs of peripheral or hard-to-reach populations, it is prudent to involve first level care facilities such as BHUs, Dispensaries and MNCH centers, and the Lady Health Workers (LHWs) linked to them, in the provision of TB services. This will also provide the pathway to universal health coverage. These facilities can help in identifying presumptive TB cases, arrange sample collection and transportation to TBMUs, carry out contact investigation, provide treatment to patients with active TB and preventive treatment to eligible persons identified with latent TB infection (LTBI). They can also help in tracing and retrieving TB patients who interrupt treatment.
At the district level, Deputy Commissioners should convene the district steering committee as ‘first amongst equals’, comprising of all economic and social sector line departments, civil society organizations, elected representatives, TB survivors, TB activists and media personalities. The District Health Officer may act as member/secretary of these steering committees and act as the secretariat by developing working papers. The Task Force should meet at least on a quarterly basis to review the program performance and the incremental benefit accruing from multi-sectoral collaboration.
Other priority tasks already on the government’s agenda include the formation of a Parliamentary Caucus on TB Control with a multi-mix of MNAs/Senators from all parties, genders and religions, headed by Dr Nausheen Hamid the parliamentary secretary for Health. The caucus will draft legislation on TB elimination issues such as mandatory notification of TB cases (already done in Sindh province) and restrict off-the-counter sale of TB medicines among other things.
The Government is also most anxious to avoid catastrophic health costs, particularly in TB patients to avoid their falling down the poverty line. Therefore, health insurance is being expanded to a greater proportion of persons in the low-income groups. Let’s hope all these measures prove enough to rid the country of this ancient disease, whose cause has been known since over a century, medication available since over 70 years and free services available throughout the country since almost two decades. We just need to cast the net more broadly to detect all the cases and provide user-friendly services to eliminate it once and for all times. It’s the least we can do for our children to provide them a safer and cleaner environment than we had. We simply cannot allow this deadly disease to devastate over 4,000 people and their families daily across the world and rob our coming generations of a TB-Free World. We are presently at the crossroads; what we do over the next ten years will determine how things shape by 2030. If missed, this chance will never come again and will have ghastly implications in terms of human and financial losses. IT’S TIME!
Copyright: Dr Ghulam Nabi Kazi
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