Problem: Tajikistan ranked among the highest TB and MDR-TB burdened countries in the WHO European Region; suboptimal TB outcomes were linked to the concentration of TB treatment in hospital settings and poor coordination with primary care, as well as inadequate monitoring systems.
Solution highlights: Following on from previous national efforts to address high TB incidence rates, the third National TB Programme 2010–2015 was approved by the government to systematically address service delivery gaps and continue to develop TB services in primary care; building on previous actions taken to reduce TB and learning from these experiences enabled a stronger approach moving forward; cross-ministry partnerships ensured united government support and greater stability for the initiative; partnerships between the government and international organizations provided an infusion of technical expertise and resources; adjusting resource allocation was used as a mechanism to drive organizational shifts in service delivery.
Description of practice
In 1996, with a tuberculosis (TB) incidence rate of 168 per 100 000 population, compared to a WHO Regional Average of 7 per 100 000 population, Tajikistan had one of the highest TB-burdens in the WHO European Region. Despite efforts being made to address TB, the incidence rate reached 221 per 100 000 population in 2001. Furthermore, multi-drug resistant TB (MDR-TB) became an increasing problem and posed additional challenges to TB reduction efforts. The suboptimal delivery of TB services, including the concentration of TB treatment in hospital settings, poor coordination with primary care and weak monitoring systems, was highlighted as a persisting barrier to TB reduction efforts.
Strengthening TB services has been a high priority for the Government of Tajikistan since the approval of the first National TB Programme 1996–2000, which was then followed by the Concept of Public Health Reform and the National TB Programme 2003–2010. Guided by these programmes, the role of the primary care sector in TB service delivery was strengthened and full coverage of Directly Observed Treatment, Short-Course (DOTS) was achieved. The National TB Programme 2010–2015 was approved by the government to continue building on these successes. The National TB Programme 2010–2015 was designed to systematically address persisting TB service delivery gaps and further expand the role of primary care. Reorganizing the delivery of services under this Programme has allowed the majority of TB patients to start receiving TB care in outpatient facilities. Over 3000 health workers have been trained on providing TB services in primary care settings and annual accredited trainings are now in place to ensure these competencies are maintained. The Ministry of Health and Ministry of Education have worked to adapt the formal education of health workers to support the optimal provision of TB services and TB education has also been incorporated into the school system to increase population health literacy on TB.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
TB reduction efforts are being directed by the national government under the oversight and leadership of the Ministry of Health, along with the support of other government ministries, international development agencies and NGOs. Government ministries work together in partnerships coordinated through the National TB, AIDS and Malaria Coordination Committee, which includes representatives from each ministry, as well as various agencies of the United Nations and local and international NGOs. Additionally, the Ministry of Health is working on establishing the Agency of Population TB Protection; the main aim of which will be to influence government ministries to step up their efforts in the fight against TB. Government partnerships with international development agencies and NGOs are also crucial to TB reduction efforts. These organizations provide technical guidance and expertise, support trainings for health workers, invest necessary resources and fill gaps in TB service delivery. While the majority of financing for the National TB Programme 2010–2015 was provided by The Global Fund, the government is gradually taking on increasing financial responsibility for TB-related activities and has the long-term goal of becoming independent from external funding.
Since 2010, data indicate declines in the number of newly-detected TB cases. TB care has shifted into lower-level settings, making TB treatment easier and more accessible for patients, and the number of TB hospital beds has been reduced. As a result, 70% of all new patients (and almost half of MDR-TB patients) are now treated as outpatients from day one of treatment.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Oktam Bobokhojaev
- Ministry of Health and Social Protection