Problem: High prevalence of TB and increasing burden of MDR-TB; admission to hospital required for all patients with TB; increased waiting times for TB care due to the longer treatment period required for MDR-TB and the continued use of a consilium model; risk of TB transmission between patients waiting for treatment and the population; potential for cross-contamination of TB strains between hospitalized patients.
Solution highlights: Médecins Sans Frontières (MSF), in partnership with the Government of the Republic of Karakalpakstan, introduced ambulatory care from day one (ACD1) as an alternative model for TB care; a strong understanding of service delivery challenges led to a solution that met patients’ needs; a supportive political and legal framework, developed prior to implementation, helped to sustainably embed reforms within the health system; strong relationships between key actors who had a history of working together aided the initiative.
Description of practice
Throughout the early 2000s, tuberculosis (TB) became a growing public health concern in Uzbekistan and rates of multidrug-resistant tuberculosis (MDR-TB) increased. MDR-TB was estimated to account for 23% of newly diagnosed TB cases and 62% of retreatment cases between 2010 and 2011. Longer treatment periods required for the management of MDR-TB (at least eight months), combined with the high number of individuals requiring care, called into question the existing treatment model requiring hospitalization for all patients during the intensive phase. The continued use of a consilium model, whereby a single group of specialists made every TB treatment decision, caused further delays. Patients waiting for treatment risked transmitting the disease to the population and a lack of segregation between drug-sensitive and drug-resistant hospitalized patients risked cross-contamination of TB strains.
In the autonomous north-western region of Karakalpakstan, a new TB care model was introduced by the Government of the Republic of Karakalpakstan, in partnership with Médecins Sans Frontières (MSF), to provide a comprehensive TB treatment strategy based on ambulatory care from day one (ACD1). ACD1 enables patients to start TB treatment in ambulatory settings, avoiding the need for hospitalization. Initially piloted in two of Karakalpakstan’s 16 districts, the initiative has since been expanded across Karakalpakstan. System-wide changes, including a new legal framework and the decentralization of decision-making structures, have accompanied the initiative to allow for locally-tailored service delivery. Extensive training for providers was carried out to allow task shifting from TB specialists in hospital settings to generalist providers at the community level. TB treatment guidelines and protocols have been simplified to facilitate their appropriate use by non-TB specialists. Investments in complementary infrastructure and resources have ensured that local health facilities are adequately equipped to safely deliver care, and rapid diagnostic technology has been introduced.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
MSF developed the Comprehensive Care for All TB treatment strategy and advocated for its introduction. The strong working relationship MSF had from collaborations with the Ministry of Health of the Republic of Karakalpakstan on other TB programmes in the region helped to secure government support for this initiative. As TB was a high government priority, the Ministry was a willing and active partner. While the introduction and early management of the initiative was led by MSF, the Ministry played a critical role in establishing necessary political and legal frameworks. A gradual handover of responsibilities from MSF to the Ministry has begun and it is expected that the Ministry will assume full responsibility over comprehensive TB programmes by 2017.
Only preliminary data on the impact of treatment with ACD1 is available as the number of patients who have completed treatment is still modest. Early outcomes are positive and suggest the initiative is performing at least as well as the previous treatment model. The proportion of patients receiving ACD1 has been steadily increasing over time. In 2012, approximately half of the 1420 patients who started TB treatment received ACD1. Median time between diagnostic sputum collection and treatment initiation fell from six weeks prior to the initiative to less than two weeks in 2015, indicating that ACD1 enables patients to start treatment sooner. Patients receiving ACD1 have also shown better adherence to prescribed drug regimens during the post-intensive treatment phase.
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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- Sebastian Dietrich
- Médecins Sans Frontières (MSF)