AFRICA

Congo-Brazzaville

The Global TB Drug Facility (GDF) and MSH have developed diagnostic laboratory kits for use in resource-poor countries with high rates of TB. These “TB test kits” contain all the essential items needed for sputum microscopy: good microscopes with backup rechargeable batteries, disposable sputum collection cups, stains and reagents to prepare the smears, and other basic laboratory equipment. Over the last year, prototypes of the kits have been piloted in laboratories in Congo-Brazzaville, Nigeria, and Tajikistan. Recent evaluation visits to these three countries have been encouraging, finding that the kits help to improve TB diagnosis. Laboratory staff members, particularly those in district and peripheral laboratories, have found the kits very useful. Staff members’ suggestions have been incorporated into the kit specifications and the kits will be regularly available through the GDF in the near future.

» Story: The Unsung Heroes of Tuberculosis Control

Ethiopia

A National Advisory Committee has been formed to improve TB and HIV/AIDS efforts in Ethiopia. In support of this work, MSH’s RPM Plus Program studied the pharmaceutical management of TB and HIV/AIDS treatment programs. MSH recommended using established procurement and distribution channels for TB/HIV commodities, and assisted this committee in defining their roles and responsibilities to improve coordination in commodity management. In collaboration with the Ministry of Health and other stakeholders, MSH worked to improve the monitoring system for medicines used in preventive therapy for TB and other opportunistic infections. MSH also provided recommendations to implement collaborative services at all sites providing antiretroviral therapy.

» MORE about MSH’s work in Ethiopia

Kenya

In 2004, to ease logistics constraints, the Kenya National TB Program began use of “patient packs,” which contain enough anti-TB drugs to fully treat one patient. MSH’s RPM Plus program has been involved with the program since the beginning, providing support on how to switch to patient packs, on the design of the packs, and on training of trainers before patient packs are implemented. RPM Plus is providing technical support in setting up a monitoring system and in conducting a study to measure the impact of the patient packs.

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Malawi

MSH has been assisting the Ministry of Health (MOH) in Malawi to expand efforts that promote collaboration between TB and HIV/AIDS programs. One example includes training of health providers to implement a cross-referral system for TB and HIV patients. In this way MSH and the MOH are aiming to increase the rate of HIV testing for TB patients, and through operations research are seeking to better understand how to incorporate TB case-finding activities at voluntary counseling and testing sites. In addition, MSH is assisting the MOH to expand services to offer HIV-positive TB patients the sulfa drug cotrimoxazole, which helps to prevent or delay the progression of HIV-related opportunistic infections.

Malawi's new sector-wide approach has eliminated direct funding for TB programs and has given the National TB Program (NTP) a broader stewardship role instead of making the NTP directly responsible for activity implementation.

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Mozambique

MSH has worked in conjunction with Mozambique’s Ministry of Health and National Tuberculosis Control Program to develop an improved work plan for TB care and TB-HIV coinfection care.

USAID and the Tuberculosis Control Assistance Program (TB CAP) have identified laboratory services as one of Mozambique's priority areas. Assistance includes strengthening the capacity of laboratory services, improving access to quality TB laboratory diagnosis, and expanding culture services to Beira province. The National TB Reference Laboratory (NRL) will be upgraded, and management will be strengthened by reviewing and updating standard operating procedures, guidelines, and supervision. In order to improve the quality of smear results, quality assurance guidelines will also be established and supported through the provision of microscopes, refresher training, and supervision.

Nigeria

The Global TB Drug Facility(GDF) and MSH have developed diagnostic laboratory kits for use in resource-poor countries with high rates of TB. These “TB test kits” contain all the essential items needed for sputum microscopy: good microscopes with backup rechargeable batteries, disposable sputum collection cups, stains and reagents to prepare the smears, and other basic laboratory equipment. Over the last year, prototypes of the kits have been piloted in laboratories in Nigeria, Congo-Brazzaville, and Tajikistan. Recent evaluation visits to these three countries have been encouraging, finding that the kits help to improve TB diagnosis. Laboratory staff members, particularly those in district and peripheral laboratories, have found the kits very useful. Staff members' suggestions have been incorporated into the kit specifications and the kits will be regularly available through the GDF in the near future.

» MORE about MSH’s work in Nigeria

» Story: The Unsung Heroes of Tuberculosis Control

South Africa

South Africa’s dual epidemic of HIV and TB presents a major challenge to health services, particularly in the underserved areas that were once called “Homelands.” Over the past seven years, MSH has worked very closely with the Eastern Cape Department of Health to respond directly to the challenges posed by TB. Through the EQUITY Project, there is improved understanding and communication about TB at the provincial and local levels; there are new and effective tools, and checklists to strengthen DOTS; and supervisors, managers, laboratory staff, nurses and doctors have been trained in TB management. Recording and reporting of TB have also been integrated into the primary health care system, and innovations to reduce treatment failures have been pilot-tested.

MSH is now working with the National Department of Health to facilitate the integration of HIV and TB services into the overall primary health care system. This process requires that TB services be fully integrated into PHC services at the district and sub-district levels. At all sites, HIV-positive clients are screened for TB, while TB patients are offered HIV testing and counseling. National guidelines have been developed for follow-up and case management. The challenge for both National and Provincial Departments of Health at this point, however, is to translate these guidelines into an integrated, efficient, and effective program at the facility level. This requires policy change, systems reform, and significant changes in provider and caregiver practices. MSH is providing technical assistance in all these areas.

The TASC II TB project in South Africa is focusing on improving the continuum of care for TB patients and those with TB-HIV coinfection. In order to achieve this, the TASC II TB Laboratory Support Team is working in collaboration with the National Tuberculosis Control Program (NTCP) and National Health Laboratory Services (NHLS) to strengthen TB smear microscopy at centers in selected districts. Better smear microscopy will help to provide more accurate diagnosis and, ultimately, better patient care and disease management.

TB laboratory information systems and indicators have been reviewed and are being piloted in one district of KwaZulu Natal Province, and a plan (scheduled for implementation in April 2006) for building capacity in TB laboratory management and quality assurance in KwaZulu Natal has been developed in line with international standards.

» MORE about MSH’s work in South Africa

» Story: Reinforcing the Basics to Improve TB Management

Uganda

MSH has worked closely with several local and international stakeholders to help Uganda’s National Tuberculosis and Leprosy Program (NTLP) expand DOTS in the country. Activities over the past year have included a literature review, formative research, and a National IEC/BCC Strategic Framework Workshop. IEC/BCC has been identified as a key strategy for TB control in Uganda and for meeting the NTLP's TB objectives.

In order to improve and expand DOTS programs, the IEC/BCC strategy targets staff in health facilities and community volunteers. Additionally, the MSH team developed—when appropriate, by adapting existing materials—a comprehensive set of IEC/BCC materials to increase community awareness of TB and improve client-staff interaction.

Uganda is one of the twenty-two highest-burden countries for tuberculosis (TB); the country’s NTLP TB objectives are to reach a 70 percent case detection rate and an 85 percent treatment success rate by 2010.

Strengthening laboratory services in Uganda
In Uganda, MSH has completed a one-year program to strengthen the management of laboratory systems by building strong interdisciplinary teams. This is a new approach in a setting where efforts to improve performance have traditionally been limited to providing equipment and supplies and training staff while ignoring underlying management and leadership issues. Technicians working in mismanaged, disorganized laboratories and with deteriorating equipment technicians were often unable to perform basic diagnostic tests for TB and HIV/AIDS. In an effort led by the Ministry of Health (MOH), the Joint Clinical Research Centre (JCRC), and MSH, new teams now oversee laboratory activities in two regional referral hospitals. These teams include medical directors, hospital administrators, laboratory managers, doctors, and technicians who share responsibility for improving their facilities.

MSH and its partners brought the teams together, facilitating a process in which staff and managers together identify challenges, clarify roles and responsibilities, develop action plans, and use a standards-based monitoring and evaluation tool to measure their progress. As a result, participating laboratories have made significant improvements using their own resources. Among the notable improvements are the first hospital budget line items for laboratory supplies, staff who hold regular team meetings to address problems, and additional space allocated to key laboratory functions. The MOH and JCRC are seeking ways to expand the successful program to other sites throughout Uganda.

» MORE about MSH’s work in Uganda

» Story: Strengthening Laboratories in Uganda: Expediting the Roll-Out of TB and HIV/AIDS Programs

ASIA

Afghanistan

Through the USAID-funded REACH Project in Afghanistan, MSH is working with the Ministry of Public Health (MOPH) and other partners to integrate DOTS into the country’s Basic Package of Health Services (BPHS). With the National TB Control Program (NTP) and key NGOs, REACH is training doctors, nurses, community health workers, and community health supervisors in TB case detection and case management through DOTS. With NTP officials, REACH staff members conduct on-site monitoring and supervision to provide quality assurance for laboratories and DOTS. The collaboration among REACH, the MOPH, and participating NGOs will bring coverage to nearly 75 percent of the country’s districts. In four provinces, REACH is working with community health workers to introduce model community-based DOTS programs, which will serve as training sites for other provinces.

In the past year, REACH has shown that rapid expansion of DOTS in a post-conflict environment is possible despite all the challenges. The number of REACH facilities providing DOTS has increased by 423 percent, and the number of patients diagnosed with and treated for TB has increased 310 percent from 2004 to 2005. With support from REACH and other partners, the NTP has reported a 200 percent rise in facilities providing DOTS and a 35 percent increase in the number of TB patients diagnosed and treated during the same time period.

MSH and REACH are also helping to support the BPHS by strengthening laboratory services for TB, HIV/AIDS, and malaria. Laboratory staff have received refresher training in order to bring their current knowledge and practical skills in line with international standards. Accurate and reliable laboratory results and services yield better management of patient care and lives saved. The refresher training program is operating in all thirteen REACH-supported provinces, 120 staff members have attended the refresher course, and MOPH plans to use the standardized curriculum countrywide for all remaining laboratory staff.

» MORE about MSH’s work in Afghanistan

» Story: Trading Despair for Hope

» Story: Escalating the Battle Against TB

» Story: DOTS Expansion Brings Hope to Afghan TB Patients

Bangladesh

MSH’s RPM Plus program is providing technical assistance to the national TB program and NGOs working in TB control to design and implement operations research and evaluation studies on incentives and enablers for increased case detection and improved treatment adherence. The studies are addressing: (1) the use of patient incentives to ensure timely referral from the chest clinics, to which most TB patients currently go, to NGO clinics for diagnosis, (2) the impact and cost-effectiveness of using cured patients to increase TB case detection, and (3) the use of patient and provider incentives for urban NGO clinics implementing DOTS.

Philippines

Tuberculosis is a major problem in the Philippines. In 2003, the country ranked eighth among the twenty-two high-TB burden countries, with an estimated incidence rate of 145 per 100,000 population. TB control is one of the important components of MSH's Local Enhancement and Development (LEAD) for Health Project, funded by USAID. LEAD provides technical support in improving local governance and enhancing the national policy environment, which helps the local government units (LGUs) to provide high-quality, sustainable TB-DOTS services. LEAD will assist 544 LGUs from 29 provinces and 26 cities covering 40 percent of the country's population.

LEAD works to increase local support for TB control by helping with the following:

• improve capability and advocacy skills, thus ensuring that sufficient resources are allocated
• pass local policies in support of TB control
• put management and information systems in place

In order to ensure the delivery of quality and sustainable DOTS services, LEAD supports the following:

• health facility certification by the Department of Health/Philippine Coalition Against TB
• health facility accreditation by the Philippine Health Insurance Corporation
• enhancement of regional and provincial capacity to help health facilities to meet TB-DOTS standards
• development of operational manuals
• organization of TB diagnostic committees
• training of health workers
• provision of microscopes

LEAD is supporting the Department of Health in its implementation of public-public mix DOTS in some pilot sites. LEAD is working closely with the National TB Control Program and other stakeholders to develop and implement a localized and zonal approach to TB control within the framework of the DOH-led health sector reform. This initiative, called Formula One, will strengthen local accountability, organize network of DOTS providers, and secure financing for TB control.

» MORE about MSH’s work in the Philippines

EUROPE & EURASIA

Central Asian Republics

RPM Plus, in conjunction with the United States Pharmacopeial Convention (USP), is carrying out an activity aimed at developing the capacity of National TB Programs to ensure quality of TB medicines through the introduction and use of thin layer chromatography (TLC) minilabs. RPM Plus and the USP will deliver minilabs to the Central Asian Republics and train pharmaceutical inspectors.

Moldova

MSH’s technical assistance in Moldova through the RPM Plus program focuses on strengthening the drug management information system for the DOTS program. This work includes the introduction of a set of indicators for monitoring purposes that will be incorporated into the monitoring and evaluation software being developed by the Ministry of Health. RPM Plus is also providing technical assistance to establish a distribution and information system for the second-line medicines to be used in the DOTS Plus project approved in February 2005.

Romania

The RPM Plus program of MSH is assisting the National TB Control Program (NTP) in Romania to develop a drug management guide for district-level staff and field-test a multipurpose stock, consumption, and ordering tool, through training of trainers and regional training workshops. RPM Plus is also providing technical assistance to strengthen the capacity of the NTP to manage the pharmaceutical aspects of a DOTS Plus project, including quantification and procurement through the Green Light Committee.

Tajikistan

The Global TB Drug Facility (GDF) and MSH have developed diagnostic laboratory kits for use in resource-poor countries with high rates of TB. These “TB test kits” contain all the essential items needed for sputum microscopy: good microscopes with backup rechargeable batteries, disposable sputum collection cups, stains and reagents to prepare the smears, and other basic laboratory equipment. Over the last year, prototypes of the kits have been piloted in laboratories in Tajikistan, Congo-Brazzaville, and Nigeria. Recent evaluation visits to these three countries have been encouraging, finding that the kits help to improve TB diagnosis. Laboratory staff members, particularly those in district and peripheral laboratories, have found the kits very useful. Staff members’ suggestions have been incorporated into the kit specifications and the kits will be regularly available through the GDF in the near future.

» Story: The Unsung Heroes of Tuberculosis Control

LATIN AMERICA & THE CARIBBEAN

Brazil

In Brazil, MSH has been instrumental in bringing providers, policymakers, and drug manufacturers together to adapt the DOTS strategy to meet the country’s heath needs and production capabilities. MSH is working with drug manufacturers and policymakers to develop a new set of fixed-dose combination tablets and to introduce a new drug management information system (DMIS). The DMIS will strengthen the Central TB Unit's capacity to monitor the treatment, distribution and use of drugs for multi drug-resistant TB (MDR-TB), and will make it possible to gradually decentralize this responsibility to regional centers. In support of a change in health policy for treating TB treatment failures, MSH organized stakeholders to develop a new protocol which has been approved by the national medical ethics council prior to initiating the clinical study. To assure that TB medicines are of good quality in Brazil, MSH frequently brings stakeholders together to review and improve quality control procedures.

» MORE about MSH’s work in Brazil

» Story: Family Health Teams Make DOTS Work

Dominican Republic

The Dominican Republic has one of the highest incidences of tuberculosis (TB) in Latin America. Inappropriate or incomplete pharmaceutical treatment of TB contributes to the country's prevalence rate of multi-drug resistant TB (MDR-TB)—again, one of the highest in the Americas. To address these problems, MSH's RPM Plus program implemented a pharmaceutical management information system (PMIS) that was pilot-tested in two areas and scaled up to the rest of the country in late 2005.

The first available data from the PMIS revealed that health facilities and provincial warehouses often did not have minimum stock of appropriate TB medication, often because the government was often paying very high prices for medication that could be more affordably procured from international markets. By changing therapeutic regimens to fixed-dose combinations (FDCs) and by purchasing these medications through the Global TB Drug Facility (GDF) mechanism the cost of medication was reduced from US$155.00 to an estimated US$23.00 per treatment regimen. With RPM Plus assistance, the GDF contract has been signed, medicines are scheduled to arrive in the second quarter of 2006, and health providers in two pilot areas have been trained in the use of FDCs.

The National Tuberculosis Program (NTP) is also facing management challenges, including the diagnosis and treatment of the HIV/TB co-infection, the treatment of MDR-TB, including the procurement of second-line TB medicines, and the administration of the financial resources provided by USAID and the Global Fund.

With the financial support of the Global Fund, MSH organized a national workshop in September 2005. Using the Management and Organizational Sustainability Tool (MOST)—recently adapted for TB control programs—five priority management areas were identified by attendees and facilitators:

• knowledge of the mission and values of the program
• coordination with other public health programs (HIV) and the private sector
• operational planning
• systems to support monitoring, supervision, and evaluation of the program
• management of operational and epidemiological information

Participants also developed a detailed and realistic action plan to address these priorities during 2006.

» MORE about MSH’s work in Dominican Republic

Ecuador

Ecuador is one of nine countries in Latin American and the Caribbean classified by PAHO as having a high burden of TB. Since Ecuador adopted the DOTS strategy in 2000, the National Tuberculosis Control Program (NTP) has made important advances in improving and expanding DOTS in the public sector facilities. However, Ecuador has identified a lack of human resources and weak management capacity of the NTP as important challenges to improving and expanding DOTS.

MSH, together with the NTP, and the Canadian Lung Association, has been working to strengthen the leadership and managerial capabilities of the NTP at both the national and provincial levels. A well-known MSH tool, the Management and Organizational Sustainability Tool (MOST), recently adapted to improve the management of TB control programs, has helped the Ecuador NTP identify and address six key management priorities: human capacity, strategic planning, leadership development, coordination with other public health programs and the private sector, linkages with communities, and systems to support monitoring, supervision, and evaluation of the program.

The NTP and MSH have developed a 2005–2006 action plan for improving management priorities; the plan has been implemented though national and provincial leaders and includes objectives, indicators, actions, resources needed, persons in charge, and a time table.

Haiti

The people of Haiti have long been overwhelmed by health problems related to rapid population growth, poverty, poor diet, and emerging diseases. Haiti has one of the highest rates of TB in the Western Hemisphere.

In 1995, MSH began working with the Ministère de la Santé Publique et de la Population and a network of NGO partners to improve the Haitian population's access to high-quality basic health services, including TB services. MSH works directly with the NTP and through two major implementing partners, International Child Care and Centre pour le Développement de la Santé, to support DOTS expansion. MSH’s technical and logistic support includes assistance in training, monitoring and supervision, commodity management, exploration of opportunities to improve collaboration between both the TB and HIV/AIDS programs, a cross-border TB initiative with the Dominican Republic, and support in the preparation of Global Fund proposals. At the same time, MSH supports initiatives that build systems that can be sustained by Haiti's own technical and financial resources in the future.

» MORE about MSH’s work in Haiti