Tuberculosis in Pakistan- Investing in the program : A Multi-pronged strategy

Video Acknowledgement : Eli Lilly and Company

HISTORY-THE INFECTIOUS ORGANISM:

The main organism which causes Tuberculosis (TB) is called Mycobacterium Tuberculosis. There has been substantial reduction in Tb incidence & prevalence by many developed countries by working on various aspects such as: less overcrowding, health promotion, health awareness and improved working conditions. This organism was discovered about 137 years ago which jogs our memory about the serious consequences not nationally but globally. This World TB day 2019 is a reminder to aggressively work towards eradication as TB was considered untreatable before 19th/20th century.

INTRODUCTION:

It is important to realize that the spread of TB is not only due to the infectious agent itself but also other socio-political factors such as limitation of access to care for the marginalized communities. The cause of TB cannot be attributed to only a health problem but a great onus lies on the socio-political aspect whenever there are low literacy levels, poor hygiene and no or poor health awareness.

FACTS & FIGURES:

The realistic approach in preventing TB in Pakistan is to precisely identify and subsequent treatment with special care to complete months of treatment in order to prevent infection to other personnel. It is logical to invest in this disease because of the following facts and figures:

·      8 million people are infected with TB annually and nearly two million die of this disease which includes approximately 0.25 million children.

·      It is the leading cause of death due to infectious diseases among young women.

·      Highest prevalence (4th) worldwide in DR-TB cases.

·      Highest prevalence(5th) worldwide in DS-TB cases.

·      Annual incidence of 0.55 million new TB cases in Pakistan.

GLOBAL EMERGENCY:

World Health Organization announced TB as a global emergency making the control and elimination as the biggest priority especially in high TB burden countries. Many countries are using the TB-DOTS strategy- directly observed treatment, short course for controlling the disease. The commitment for any country to effectively tackle this epidemic requires strong political commitment which results into regular supply of drug, recording & reporting mechanism to monitor progress, patient follow up by a health worker, case detection through sputum smear microscopy, all of this translating into proper resource allocation.

PAKISTAN’S PERSPECTIVE:

Pakistan’s government announced TB as a national emergency in the year 2001, designing a set of interventions with the support of WHO and subsequent funding. In year 2014, the WHO proposed the End TB strategy with an aim to end the TB epidemic globally by aiming to reduce deaths due to TB by 95% and 90% reduction in TB cases by the year 2035. It also aimed at reducing the catastrophic expenditure in reference to TB globally. This strategy led to formulating interim targets for the year 2020, 2025 and 2030.

In year 2002, an organization named The Global Fund was founded as a joint venture and collaboration to reduce the cases and deaths associated with Malaria, HIV/AIDS and Tuberculosis. Pakistan drives approximately 90% of its grant assistance from The Global Fund to work on Tuberculosis, HIV/AIDS and Malaria along with the help of private sector, civil society, and supporting procedures and policies. The Global Fund is a contribution from many countries but chiefly from United Kingdom, Germany, Sweden, Canada, United States, Norway, and European Commission along with partners like Bill & Melinda Gates foundation. The Global Fund accumulates nearly $ 4 billion directed towards countries and communities bearing the highest load of diseases. Another organization based in Geneva, named Stop Tb Partnership is also devising policies and structure partnering with more than 100 countries and 1700 partners including governmental organizations, private sector, funding and research organizations, civil sector, private sector and other international technical organizations.

THE LEADERSHIP:

The top civil and political leadership of Pakistan has made promising statements in the past in not only reducing Tuberculosis but also bridging the financial gaps and implementation loopholes by devising a national strategy named TB National Strategic Plan 2017-2020. The vision of the top leadership has resulted into a ripple effect for the provisional and district government to start re focusing their efforts on a) Access to healthcare facilities specifically TB reduction services through public private node b) Enhancing functional capacity of the laboratory and c) Strengthening healthcare system holistically. The TB success rate in Pakistan is on the rise since past few years . There is a very strong evidence that more stringent measures needs to be exercised by the provincial governments to seize more TB cases specially those who are approaching general practioners and quacks in low settlement areas. There is sufficient evidence available which states that wrong regimen and medication actually converts a drug sensitive patient into a drug resistant patient and finally to XDR-TB. From year 2017 till 2018, a comprehensive figure of 381,518 TB cases nationally were put on treatment indicating a strong inclination towards eliminating Tuberculosis by the government.

ADVANCEMENT TOWARDS MULTI-PRONGED STRATIGIES:

Forceful exercise towards promoting a healthy life style and awareness creation for TB requires a multi-pronged strategy. An inclusion policy basing on human rights can be an ideal approach for TB control. Few of the potential strategies can be listed as :

a-         Academicians by adding the latest TB control methodologies in the undergraduate medical curriculum.

b-        Improving access by using all health facilities for TB services while improving their visibility and active case finding by tapping private sector practitioners, pharmacies, laboratories and hospitals is a clear way for developing an equitable financing mechanism

c-         Social safety nets like health cards/vouchers, Zakaat, Baitul Maal and BISP.

d-        Media, celebrity personalities, social activists, TB survivors for awareness and prevention of TB.

e-         Strengthening the monitoring and evaluation and accountability framework while focusing on low performing provinces or districts.

f-          Inclusion of equity based financing mechanisms and highlighting value of operational research.

GLOBAL COMMITMENT:

The commitment of global leaders towards ending and preventing TB is well depicted in the recent meeting held in September 2017, The united Nations General Assembly. The relevant stakeholders vowed to increase TB funding by $ 13 billion annually by 2022 and $2 billion for research avenues. The countries and regions affected by TB and how it affects their daily life, the enormity was recognized by the attending 193 members including 15 heads of state. The forum realized the need to end the TB epidemic globally by 2030 by working on parameters such as sustainable financing, universal access to diagnosis, care and treatment. Pakistan’s foreign minister Shah Mehmood Qureshi represented Pakistan and vowed that the present government is fully committed in implementing the End TB Strategy. The need for continuous coordination between health programmes HIV & TB was also discussed to ensure complete elimination and subsequent treatment and care.

FACTORS FOR DR-TB BURDEN:

The marginalized population living in Pakistan which includes people living in far flung areas of the four provinces, living in prisons, migrants or refugees or individuals with multiple co morbids are more prone to health diseases including TB. The DR-TB burden on Pakistan is enormous and can be attributed to few challenges such as:

·      Low literacy rate amongst provinces especially in the female gender.

·      Delay in diagnosis

·      Prescribing of Inadequate and unsupervised drug regimen amongst healthcare professionals.

·      Poor support system for those individuals with TB which leads to reduced follow up at treatment centers.

Amongst the points mentioned above, the most important one, delayed diagnosis has very strong implications. The delayed diagnosis leads to being ill for a longer period of time and therefore difficulty in treatment due to progression of sensitive stage to resistant stage in TB. As the disease progresses into difficult stage it leads to socio economic burden such as malnutrition, sale of livestock, decreased quality of life, lost income which leads the household into deeper poverty.

THE HUMAN RIGHTS APPROACH:

TB has been already recognized as a curable disease but the discrimination and social stigma attached with this disease is difficult to address by the health professionals only. The need of the hour is to have a holistic perspective as an avenue to prevent and eradicate TB by community engagement. This engagement requires to exercise human rights approach by following few main strategies such as:

a-         Priority development,

b-        Monitoring, evaluating and implementing tools to analyze the progress,

c-         Timely planning and decisions,

d-        Participation of community,

d-         Inclusion/involving the marginalized/vulnerable population of the society.

It is imperative to realize the need of a bigger role to be played by the public health and more importantly health systems personnel in improving the service delivery by exercising best practices. Amongst the best practices such as: adequate attention to marginalized communities/group(s); inculcating the concept of equity and equality; ensuring privacy and confidentiality among affected individuals, and helping in reducing the discriminatory attitude and subsequent stigma associated with TB patients. This cross-sectional approach (empowerment & participation) is advantageous because it creates a harmony amongst the patients and community which serves the interests of both groups. A multi sectoral approach in frequency with the cross sectional approach helps to channelize the efforts by all groups of the society in promoting health and avoiding disjointed approaches/interventions.

The new approach to TB requires innovative thinking which in return stimulate rational parameters to effectively act on the Stop TB agenda. It is important to analyze human rights principles such as: end to discrimination, education and freedom in helping to achieve bigger country or provincial agenda. Considering the situation in Pakistan, females are subjected to gender discrimination which results in high risk to disease contradiction and subsequent threat to health. It is difficult for females living in far flung areas to access healthcare facilities as in majority of the cases the decisions are inflicted on them by the male members of the household. These types of cultural barriers make females more prone to health hazards, education, information and freedom of movement.

WAY FORWARD, ENGINEERING THE PROGRAM:

Pakistan, amongst one of the low literacy country needs to channelize a lot of efforts specially in the domain of human rights such as: respect, equity, education, freedom and tolerance towards the marginalized cohorts. The engineering of public health programs specially TB control needs to be planned in such a way that it inculcates or address the main points mentioned below:

a-         A collaborative, tolerant and supportive environment between communities.

b-        Reducing the stigma and acceptance amongst different communities living in a district/city/country.

The human being approach and public health engineering are mutually exclusive approaches which reinforce each other. Human rights in solving health crisis being a diverse approach is instrumental in assessing the performance of civil society and government of the country.

INTERVENTIONS FOR VULNERABLE POPULATION: LEARNING FROM PUNJAB & BALOCHISTAN:

The TB reach programme has proved in being a concrete slab towards reaching the vulnerable populations especially in the provinces of Sindh and Balochistan. This initiative was undertaken in collaboration with the Stop TB partnership based in Geneva. The first example that was well depicted by the Government of Punjab in TB screening and provision of treatment in prison. The TB DOTS programme through its linkages screened two hundred thousand prisoners in year 2013 and those infected were put on subsequent treatment. The preventive care approach was also exercised for the inmates where severe overcrowding was observed. This approach was also expanded to new prisoners being admitted to jails and those being released from jails in order to hamper the spread into a large community. One of the major reasons for TB spread is due to the overcrowding in jails specially in the biggest province of Pakistan., Punjab having thirty percent more inmates than the original capacity without proper mechanism of ventilation.

The other group of vulnerable population for TB which is coal miners are being screened and subsequent preventive measures through the TB Reach programme. The coal miners especially in the coal mining districts of Balochistan are potential sites where the provincial TB Control programme of Balochistan along with private organizations are exercising their focused approaches. The Programmatic interventions include: i) mapping of the coal mining sites, ii) screening of miners through mobile X ray vans, iii) collection of sputum for presumptive cases, iv) Testing at gene Xpert sites for Rif resistance and Non rif resistance, v) Enrollment and initiation of TB treatment at a nearby quality facility with the specialized vi) verbal screening on households and associated communities/area(s) where the index patient resides.

RESEARCH & DEVELOPMENT:

The provincial TB control department is exercising an effort district wise for a brief interval to put the households of TB patients specially DR-TB patients on prophylactic treatment. A cash transfer program through social support is also in working for DR-TB patients to provide incentive (a type of financial support) for basic transport and nutrition expenses for every visit. A series of sessions on advocacy and awareness are being organized by private NGO’s towards the ministry representatives and marginalized/vulnerable groups respectively. There has been a contemporary introduction of female health care workers approaching the households which are otherwise difficult to be tapped due to cultural and religious barrier based on gender identity. The inclusion of inspiring and famous media personalities has also been exercised to support the advocacy campaign for the masses/communities and representatives in the government policy groups.

There has been an ongoing global effort in terms of consistent research in development and testing of medicines and therapy to treat and prevent tuberculosis effectively and efficiently. The policy makers in Pakistan, holistically in sub-continent needs to structure and devise policies in order to adjust the health care system at large to eradicate Tuberculosis. This will largely help in providing a safe zone for the upcoming future generations.

CONCLUSION: THE WAY FORWARD

The sustained efforts being implemented from the policy level to the field level by partnerships such as Stop TB, The Global Fund, End TB, are a source of hope that this world will soon be free from tuberculosis. The intensity (morbidity & mortality) and penetration into vulnerable/marginalized communities of TB cannot be denied but the implementation of financial, R&D, physical resources is worth in not only reducing the economic burden of low and middle countries but also safe and healthy future generation. The efforts being channelized such as TB Control programme in Pakistan are depicting a promising picture. Now efforts should be drilled into the power corridors for policy making, an approach to better address the human and economic development for future. The introduction of GeneXpert machines in analyzing sputum smears for the resistance pattern has revolutionized the diagnosis of TB. There is a greater need to introduce platforms for innovation and development for the upcoming researchers and infectious diseases specialists to address tuberculosis efficiently. It’s high time that other communicable diseases should also be tapped in due time.