Lessons Learned in Strengthening Health Systems for Tuberculosis Control in Developing Countries

Dates: May 4-8, 2009, Hosted by GHDonline, www.ghdonline.org

Lead Discussant: Daniel Osei, Deputy Director for Planning and Budget, Ghana Health Service

Question No. 1 (Trinidad and Tobago):

In your experience, what have you observed as weaknesses in health systems that tend to hinder the successful implementation of TB Infection control programmes in developing countries? What were some of the more successful measures undertaken to address them?

Responses:

1. Daniel Osei (Ghana), HSAN Founding Member and Deputy Director for Planning and Budget of the Ghana Health Service:
   
   Health system structures in developing countries tend to be very weak. Most of the weaknesses are in the human resource numbers, capacity and equipment. This has made it difficult for central systems to support the scaling up of many interventions supported by vertical programme funding. Secondly, many programme managers tend to be restrictive and tend to operate outside the health system structures.
   
   In Ghana, most programmes work closely with themselves and the health system in the development of the health sector Programme of Work and budgets. In doing so, the weak areas are addressed to complement programme support. The Ghana TB infection control strategy has provided microscopes (jointly with National Malaria Control Programme) and other equipment to existing laboratories to be used not only for TB work but other investigations as well. Staff at health facilities has been trained in infection control and quality assurance policies and guidelines. New laboratories have been built or renovated (some jointly with HIV/AIDS programme) and equipped for health facilities who do not have laboratories (instead of constructing laboratory outside the health facility specifically to deal with TB control). The Ghana TB programme has a classic experience in working with the private sector/civil society organization on the supply side services.
   
   In my experience, the joint planning arrangements should start at the stage of planning the proposal. Sharing of resources with other programmes and the health systems is essential in avoiding parallel systems. Beyond the public health system, there is a lot to learn from the use of private sector/civil society organizations.
2. Altaf Ahmed (Pakistan), Laboratory Director, Indus Hospital
   
   People who really know about tuberculosis diagnosis, management and control have never been acknowledged and never been taken as stake holders by the Health Ministry. Diagnostics has never been looked after for quality assurance programmes. Infection control as a subject has never been taught in medical colleges and has never been part of nursing curriculum. Yet, international donors, inspite of knowing the corruption in the health system, have been donating large sum of money without getting a positive feedback thus creating more chances of corruption.
   
   Best thing which happened now is the start of public/private partnership which is still in infancy. Some NGOs are trying individually to create awareness and opportunity for learning infection control.

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Question No. 2 (Trinidad and Tobago):

Most TB experts are advocating for the integration of TB services into primary health care as a means of strengthening the delivery system for TB. What are some practical steps that need to be taken to ensure that such integration materializes?

Responses:

1. Daniel Osei (Ghana), HSAN Founding Member and Deputy Director for Planning and Budget of the Ghana Health Service:
   
   There is no doubt that programme sustainability especially in developing countries depends on a strong health delivery system. However an entry and exit strategy is critical to achieving this objective. More resources are spent on the entry strategies. The exit strategies are after thought and takes place at the end of the project, leaving governments to sustain the programmes.
   
   A few practical examples:
   • As much as possible strengthen/improve existing system to deliver TB services as part of integrated service delivery
   • Ensure integrated M&E systems
   • Avoid labeling support as TB. only related support. E.g TB information officers, TB computers for collating TB data etc
   • Avoid creating TB coordinators at primary levels though a national programme manager is essential especially at the beginning of programme implementation.
   Ghana is making use of the private sector (example chemical sellers) at the community level.
2. RK Sahu (India), Technical Specialist, Abt Associates Inc.:
   
   In India, Accredited Social Health Activists (ASHA) are the last leg in delivering primary health care. RNTCP is seriously considering including ASHA for delivering TB services in National Rural Health Mission (NRHM).
3. Moses Bateganya (Uganda/USA), University of Washington:
   
   I just wanted to add that an important step in the process of integration related to training health care workers to be competent in managing and control of TB which in many countries has been running as a vertical program.
   
   I have been wondering if there are minimum set of competencies for TB and TBHIV that have been developed to guide intergration of TB clinical care and control into training curricular from pre-service to in-service? To me this would be a good step in integration.
4. Prof Shaheen Mehtar (South Africa), Head of Academic Unit for Infection Prevention and Control, Tygerberg Hospital & Stellenbosch University:
   
   Dear Moses,
   
   What a wonderful breath of fresh air you are! I have been in IPC (Infection Prevention and Control) for 35 years mainly in the UK and we were very proud of our containment policies because these were wide and all-embracing. If the basics are in place, the rest follows. I totally agree that with TB, as with HIV, teaching has been in silos and no one is really aware of what someone else is doing; therefore, complete IPC policies cannot be implemented. The only way to understand IPC is that it is a PROCESS of Quality CARE; therefore, it cannot be in a vertical programme. All the IPC training courses (including the two-year Post graduate Diploma in IPC) we run are wide to ensure understanding of IPC at a fundamental level. Thereafter, the implementation of PPE, ventilation and other IPC measures just fall into place, such as isolation, segregation, etc. All these aspects are covered anyway in hospital design, risk assessment and management, microbiology and decontamination and sterilization. We know that in Africa, at least 10% of infection both HIV and TB are nosocomial -- should we not be talking about bronchoscopy, decontamination and other related topics?
   
   However, the sad thing is that this is not universal and often causes more confusion than clarity- the result is that these TB programmes are not sustainable without ownership.
   I agree with you totally!!
   
   Shaheen

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