Local realities in tuberculosis (TB) care and control

The Global Fund's 4th Partnership Forum will soon open in Sao Paolo, Brazil (28-30 June 2011). In the lead up to the Partnership Forum, the CNS Stop-TB Initiative is opening a time-limited online discussion (9-23 June 2011) to document voices from the frontlines on issues around TB care and control in local contexts. The guiding question is: what are the challenges and successes in TB care and control in your local setting? Please have your say.

37 comments:

  1. Dr Lt Col V P Gopinathan, India09 June, 2011

    The issues I wish to highlight in my local settings are:
    - Delay in early diagnosis-Problems.
    - Inadequate and irregular treatment.
    - Co-morbidities modifying treatment outcome
    - MDR/XDR Tuberculosis - continuing to challenge the programme
    - Attitude of governmental, public and supporting staff

    Dr Lt Col V P Gopinathan, India
    Email: vpgopinathan@gmail.com

    ReplyDelete
  2. Dr Muherman Harun, Indonesia10 June, 2011

    I am telling all my TB patients 2 simple things:

    1. If you get proper treatment right from the beginning, you will get cured, become healthy and have a successful life.

    2. But if you don't get proper treatment, your future may be disastrous. Heaven forbids.

    Dr Muherman Harun, Indonesia
    Email: muhermanharun@gmail.com

    ReplyDelete
  3. In our local setting,
    1. people delay to go for right treatment because of counter prescription for antibiotics and cough syrups for coughs and when the cough is persistent, the go to hospital for the right diagnosis and treatment.
    2. Due to delay in treatment, a few or most of the family member become infected.
    3. During treatment, the other family members are not traced to see whether they have acquired the infection in the process due to close contact with the patient. To make the matters worse, if it is an MDR case

    ReplyDelete
  4. Eric Aborgah13 June, 2011

    Main challenges impeding progress in TB care and control in Ghana include:

    1.Low motivation of laboratory staff.

    2.Poor or low enhancement of safety in TB laboratories.

    3.Unbridled bureaucratic inertia characterising the TB logistics system.

    4.A laboratory/technical staff needs to be included in the logistics team to facilitate procurement of reagents/apparatus/commodities of the right specification and quantity.

    Eric Aborgah
    Finasol Consult, Ghana
    Email: eraborgah@yahoo.com

    ReplyDelete
  5. Dr PS Sarma13 June, 2011

    In the local settings, there are still many bottle necks for effective TB care and control.

    1. Lack of awareness regarding TB disease: Even today in some of the rural and agency areas people have no idea regarding TB disease - how it is caused - how it will be diagnosed - where they get the drugs? etc- we clearly need more Health Education.

    2.Lack of motivation and involvement of the Private sector in the diagnosis and treatment modalities

    3.Reluctance on the part of the Public to use and utilize the government health facility

    4.Reluctance on the part of the Private Sector to refer to the government health facility

    5.NGOs working for the cause of TB need to be given more encouragement and incentives.

    6.Better coordination and cooperation between the government and private health facilities.

    Dr PS Sarma
    SMLS Trust, Amalapuram, AP, India
    Email: drpappuss@yahoo.co.in

    ReplyDelete
  6. despite the success of DOTS program, there is no fulproof mechanism to ensure that patients continue with treatment. It is not uncommon for them to leave the treatment in between, once they start feeling better.

    diagnosis in case of children and women is often delayed (or does not happen at all) due to a careless attitude and social stigma still attached with the disease.

    many patients who are on treatment, continue to smoke and eat tobacco which aggravates the problem. Effective tobacco/smoking control measures need to be taken.

    ReplyDelete
  7. despite the success of DOTS program, there is no fulproof mechanism to ensure that patients continue with treatment. It is not uncommon for them to leave the treatment in between, once they start feeling better.

    diagnosis in case of children and women is often delayed (or does not happen at all) due to a careless attitude and social stigma still attached with the disease.

    many patients who are on treatment, continue to smoke and eat tobacco which aggravates the problem. Effective tobacco/smoking control measures need to be taken.

    ReplyDelete
  8. -community health systems strenghthening is one area that needs attention
    -resumed & increased funding must be made available to NGO/CBO complimentin the work of the ministry of health
    -The CCM has to be strengthened to provide better oversight of global fund monies
    ZAMBIAN PICTURE

    ReplyDelete
  9. Abdulai A. Sesay15 June, 2011

    As TB continues to pose threat among people in Sierra Leone, so we have many challeges in the drive towards TB elimination. The Challeges face in my locality(Sierra Leone) are not limited to the following:

    -Much emphasis has be place on HIV/AIDS campaign forgeting the fact that TB is a threat among people living with HIV/AIDS and is the fastest killer disease.

    -Lack of Civil Society involvement into the camapign against TB

    -Inadequate monitoring on TB activities in order to deliver TB services effectively.

    -Government is not putting priority to TB elimination all their attention is on HIV/AIDS and one can not eliminate HIV/AIDS without fighting TB.

    Lack of awareness raising on TB as people do not know the consequencies of TB and that it poses stigma as people afraid of showing themselves about the diseases.

    This even made lot of CSOs to loose interest on the campaign against TB because they themselves are ashamed of coming out.

    Lastly, information about TB in Sierra Leone is silent thus there is need for popularisation.

    Thanks

    Abdulai A. Sesay
    National Director
    Civil Society Movement Against Tuberculosis in Sierra Leone.
    movementagainsttb@hotmail.com
    abdulaipeacemaker@hotmail.com
    +23276-202849

    ReplyDelete
  10. TB continues to take lives of many more so PLHIV yet its curable!
    Many challenges still exist, to hghlight just a few
    1)Lack of knowledge about TB, leaders mostly are innocently ignorant about this killer disease
    2)Low motivation for Community health workers or TB survivors who volunteer to senstize communities on TB
    3)Do the TB and HIV programs talk/work in practicality and not on paper to enhance management of the two diseases?
    4)Punitive laws that imprison TB treatment drug defaulters should be checked and done away with, instead put in place mechanisms to assist TB patients adhere to their treatment
    5)Food policy in prisons should be looked into, TB patients or those co-infected by HIV should be put on some sought of special diet
    6)We need more funding for community TB activities, Funding for example GFATM is very effective but their cycle of disbursement is checked to ensure no delay
    7)Meaningful involvement of the infected and affected communities in responding to TB is very vital,

    ReplyDelete
  11. Winter Musonda, Zambia17 June, 2011

    CONTACT TRACING

    We don't have a proper system for multidrug-resistant TB (MDR-TB), extensively drug-resistant TB (XDR-TB) contact tracing. We are sitting on a ticking time bomb.

    Winter Musonda, Zambia
    Eamil: msondamutoba@yahoo.com

    ReplyDelete
  12. Coulibaly Gaoussou, Côte d'Ivoire20 June, 2011

    Tuberculosis and AIDS affect the victim in Côte d'Ivoire in terms of his integrity, dignity, social and family life, work, education etc. They mainly affect the disabled and produce serious effects on the economy.

    According to the WHO report, 21,096 TB patients of all forms were detected during the year 2009 including 13,470 patients of smear-positive pulmonary tuberculosis. Children account for 3% of smear-positive pulmonary tuberculosis is detected 429 cases. For women, they represent 40% of detected smear-positive cases is 5420. Being reported 4829 HIV-infected TB 31% of TB patients tested.

    The spread of cost recovery for acts of care at all levels of the health system resulted in a decrease in the accessibility of the poor to basic health care Traditional medicine is the main use of care.

    If the Global Fund became involved in a great and lasting very real hope it would increase the budget of the fight against TB and to offer directly to the associations involved in the difficult work of support.

    Coulibaly Gaoussou, Côte d'Ivoire

    ReplyDelete
  13. Willy L Mbawala21 June, 2011

    Challenges in TB care and control in local contexts include:

    1. Delays in TB diagnosis attributed to inadequate diagnostic facilities especially in rural settings, irregular supply of lab supplies, shortage of lab staff, poverty and long distances to the diagnostic centres. Inadequate community knowledge, unfavourable attitude and practice due to lack of effective ACSM strategy on TB.

    2. At least 50 MDR-TB patients have been started on SLD and 24 of them are now on continuation phase of treatment back in their local communities - stigma, poor nutritional and psychosocial support, transport costs to and fro treatment centres, availability and cost of follow up lab investigations, knowledgeable health providers and drug management are the realities.

    Willy L Mbawala
    TB Technical Officer
    PATH Tanzania TB/HIV Project
    Email: wmbawala@path.org

    ReplyDelete
  14. Dr Shanta Ghatak, India21 June, 2011

    What can be really delivered when we expect the sick patients to be handed over 3 or 4 coloured paper slips so that the Patient can hand over one of them to the lab technician when he goes to do the microscopy, one to the medical officer, one he retains for himself and one to the provider who retains when he is referring the patient to the national program !! ( a normal person is unable to do it properly and we are considering the sick people, more or less not very literate ones to follow instructions so meticulously?)

    Tell me someone HOW is this benefitting the patient? Isn't it ONLY helping projects stay alive? There is no food, no proper DOT provider, providers are screaming their heads off as the medicine and consumable delivery system is so poorly organised, but reports say so many things that have been achieved... good tracking, quality DOT, quality treatment adherence etc

    Does anyone bother about the patient? who is sick, frail, and continuously losing hope, giving up on their own thoughts and presence and just listlessly continuing with whatever the system dictates!

    Any move regarding reaching out at the community level has to be quantified.

    Any project needs to be monitored better. Any person who is dictating terms should visit at least one human being who is suffering from TB /DR TB and accountability must be ingrained in any system which is doing TB work at any level.

    I fervently hope that there may be some provision where TB patients get at least some food and money while on treatment, some support for their
    children has to be endorsed from the national level.

    Any takers?

    Dr Shanta Ghatak, India
    Email: drshantaghatak@gmail.com

    ReplyDelete
  15. Vanajaa Augustine, Programme director, DAC Trust, Theni District, Tamilnadu, India
    And convenor of state level network for ngos working for tb control, tamilnadu
    vrvanajaa@dactrust.org

    Main Challenges on tb control services and schemes faced at Theni district and in tamilnadu for the past one decade are mentioned below

    a. NO REAL DOTS AS PER THE NORMS, TABLETS ARE BEING GIVEN IN ADVANCE
    B. LESS COVERAGE IN THE INACCESSIBLE AREA, NO SPECIAL EFFORTS TO IMPROVE THE ACCESS HAVE BEEN TAKEN PLACE, EVEN UNDER RNTCP SCHEMES ONLY LESS AMOUNT IS BEING SANCTIONED WHICH WILL NOT BE SUFFICIENT TO IMPLEMENT IT.
    C. ONLY THE BIGGER NGOS ARE IN A POSITION TO GET THE RNTCP SCHEMES BASED ON ITS NORMS AND LESS AMOUNT, EVEN THOUGH MORE NGOS ARE WORKING FOR TB.
    D. NO GOVERNMENT AND NGO COORDINATION OR JOINT MEETINGS. THIS IS VERY GOOD AT HIV AIDS FIELD BUT IT IS VERY MUCH MISSING IN TB FILED
    E. VILLAGE HELATH NURSE - VHN IS BEING GIVEN MORE WORK WHICH DOES NOT ALLOW HER TO TAKE UP MORE WORK OR MORE COUNSELLING OR DOOR TO DOOR ACCESS TO DOTS.
    F. LESS PREFERENECE FOR TB CONTROL ACTIVIITES AND FOLLOW UP AT PHC LEVEL
    G. STILL MORE VACANCIES AT BLOCK LEVEL FOR LAB TECHNICIANS – THIS IS NOT ALLOWING THE POOR TO GET PROPER TREATMENT
    H. SCARCITY OF DISTRICT LEVEL TB OFFICERS, ONLY INCHARGE HAVING ADDITIONAL DEPARTMENT WORKS
    MORE CHALLENGES ARE THERE. IF NGO AND GOVT WORK TOGETHER THEN DEFINETELY WE CAN ACHIEVE OUR GOAL IN ERADICATING TB FROM THE STATE AND INDIA. FOR THIS NGOS WORKING HERE AND THERE SHOULD JOIN TOGETHER.

    VANAJAA AUGUSTINE

    ReplyDelete
  16. Vanajaa Augustine22 June, 2011

    Main Challenges on TB control services and schemes faced at Theni district and in tamil Nadu for the past one decade are mentioned below:

    a. No real DOTS as per the norms, tablets are being given in advance

    b. less coverage in the inaccessible area, no special efforts to improve. Efforts to improve the access have been taken place, even under RNTCP schemes only less amount is being sanctioned which will not be sufficient to implement it.

    c. Only the bigger NGOs are in a position to get the RNTCP schemes based on its norms and less amount, even though more NGOs are working for TB.

    d. No government and NGO coordination or joint meetings. The NGO-government coordination is very good in HIV/AIDS field but it is very much missing in TB field

    e. Village health nurse is being given more work which does not allow her to take up more work or more counselling or door to door access to DOTS.

    f. Less preference for TB control activities and follow up at primary healthcare level

    g. Still more vacancies at block level for lab technicians – this is not allowing the poor to get proper treatment

    h. Scarcity of district level TB officers, only in-charge having additional department works

    More challenges are there. If NGO and govt work together then definitely we can achieve our goal in eradicating TB from the state and India. For this NGOs working here and there should join together.

    Vanajaa Augustine
    Programme director, DAC Trust
    Theni District, Tamil Nadu, India
    Convenor, State network for NGOs working for TB control
    Email: vrvanajaa@dactrust.org

    ReplyDelete
  17. Jitendra Dwivedi22 June, 2011

    It is difficult to diagnose extra-pulmonary TB in people living with HIV (PLHIV). Tools don’t exist in every district and by the time patient gets the right diagnosis and treatment, lot of damage and suffering has already happened (and patient has lost significant amount of money)

    Jitendra Dwivedi, India
    Abhinav Bharat Foundation (ABF)
    Email: jitendraabf@gmail.com

    ReplyDelete
  18. Saeeda Diepa22 June, 2011

    Treatment literacy is a challenge - about TB prevention, risk factors, diagnosis, treatment, adherence etc)

    Saeeda Diepa, Pakistan

    ReplyDelete
  19. Shailendra Pandey, Nepal22 June, 2011

    Lack of infection control in community settings, healthcare settings

    Shailendra Pandey, Nepal

    ReplyDelete
  20. Amir Siddiqui22 June, 2011

    Drug-resistant TB - is an outcome of poor TB control in our local settings

    Amir Siddiqui, Bangladesh

    ReplyDelete
  21. Rahul Kumar Dwivedi, India22 June, 2011

    Low awareness of TB-diabetes co-morbidities, TB-HIV co-infection, and risk factors such as tobacco use

    Rahul Kumar Dwivedi, India

    ReplyDelete
  22. Anand Pathak, India22 June, 2011

    Diagnosing TB is so difficult even in this 21st century. Genital TB, TB in children, extra-pulmonary TB, TB in people living with HIV (PLHIV)... so difficult to diagnose and often treatment begins just on suspicion without confirmed diagnosis

    Anand Pathak, India

    ReplyDelete
  23. Pastor Phainos Muhindi22 June, 2011

    Country-level partnerships must be strengthened. These are based on the practical grassroots work, especially for improving the effectiveness of partnerships in responding to the TB and HIV epidemics.

    Pastor Phainos Muhindi
    Eldoret, Kenya
    Email: phinosmuhidi@yahoo.com

    ReplyDelete
  24. Challenges in our local setting are:
    • By now, irregular flow of the funds is posing major challenge for the better implementation of the programme.
    • With the passing of time, the programme is loosing its simplicity and is being overburdened with the lots of paperwork due to which our key workers are not properly focusing on the field work or their scheduled work for which they are meant.
    • Proper monitoring of the programme is not happening from out side the local area. Monitoring teams like JMM, SIE, CIE or external evaluation teams are not regularly visiting the areas. In absence of this, key workers becomes lenient and chances of manipulating the data becomes easy.
    • RNTCP is launched as the horizontal programme with the health system in the state. This is the major cause of worry for the programme especially in the eastern part of U.P. in India. Key staff that belongs to the govt. setup, most of the time they are not as sincere towards the programme, as RNTCP’s contractual workers. Most of the times, they are bearing the responsibilities of implementing other national programmes and their other routine works, they are not able to deliver their best in order to achieve goals of the RNTCP. Therefore, it is worth suggestible that RNTCP should be converted as a vertical programme to the health system.
    • The contractual workers, although works sincerely, they are neither tends to stay in the job, nor they feels attach by their heart and soul with the job. The major reason for this tendency is the unsatisfactory remunerations they receives from the job, that is very low in compared to their equivalent counterparts in the govt. job. For this reason, the programme is not able to attract competent workers suited for the job. The guiding principle is “ if you offers peanuts, you will get only monkeys.” It is worth suggestible that the remunerations of the contractual workers should be slightly higher than that of their equivalent collaterals in govt. job, since they are not getting any benefit of govt. service.
    Avinash Krishna Srivastava
    TB Clinic Faizabad (U.P.)India
    +919455593838
    avinash_only2000@yahoo.com

    ReplyDelete
  25. Anonymous23 June, 2011

    The Issue I would like to raise is about collaborative approaches to addressing HIV/TB co-infection at district and sub-district levels. The National level plans for HIV/TB collaborative objectives are not undertsood and hence not realised.
    We know that there are strong HIV programs at district and sub-district levels as well and TB programs but there is no effort to link these programs. Overlapping areas are not identified; like INH prophylaxis for HIV+ people should be covered under both, so that people can get it in either site.

    The other big issue is lack of understanding of managing childhood TB, we can go a long way with the apporaches we know work and can be sacled -up easily.

    Zari Gill
    World Vision International

    ReplyDelete
  26. This is very true that the collaborative activities between the two agencies i.e. RNTCP and NACO/UPSACS is not clealy formulated. Lack of proper infrastructure at sub district level poses serious problems in conducting TB/HIV intensified programme in our local setting. SACS is using setting and manpower of RNTCP, but what is it doing for strengthening the infrastructure at different level, is not clear.

    ReplyDelete
  27. Eric Aborgah01 July, 2011

    If we cannot assist the TB patient through the necessary bureaucratic procedures when accessing health care in our hospitals then lets put systems in place to make them literate and conversant with hospital procedures. In fact poverty is a major barrier to TB control.

    The poor sick patient is malnourished and had to contend with the financial burden and inconvenience of travelling several km to seek treatment. Political commitment is imperative. A well fashioned comprehensive national nutritional policy to support TB Treatment is the way forward. The issue of poverty and TB should feature prominently in the national agenda for "Poverty begets TB and TB begets poverty".

    Eric Aborgah
    National TB Reference Lab, Ghana
    Email: eraborgah@yahoo.com

    ReplyDelete
  28. Dr Shanta Ghatak, India01 July, 2011

    Thanks for responding Eric. It has been my feeling for some years that we are really not doing enough for the TB community.

    Ability and efforts are not optimised due to certain cold facts like -

    1) nurturing political objectives while superficially delivering some slap dash TB service

    2) Program managers just whiling away time for data generation for their own supremacy during high level interactions

    3) Lack of basic compassion for any diseased individual as such.

    I am a sad mute witness to several hundreds of activities which never took place but authorities gained acceptance by submitting well briefed and excellently documented reports.

    Plenty of places which do not have yet proper trainings on DOT are having to start DOTS Plus within a short span of time in several areas. Can you believe it ? What sort of injustice this is ? And NO ONE is preventing also because they are not capable , or scared or deliberately musing thinking this deluge will stop on its own ......?? What are we trying to address globally is definitely NOT being heard LOCALLY .

    Each one of us believes something needs to be done. BUT each one is not resisting enough the some things which are happening in reality - WHICH should not happen at all !!!

    Dr Shanta Ghatak, India

    ReplyDelete
  29. Dr Manjula Datta, India19 July, 2011

    I think the problem is the "one size fits all" approach that the National programmes tend to take. Vulnerable populations have special needs and these should be taken into account. For example a PHC that functions 9am - 5pm cannot serve a fisherman community or a patient box based approach expecting to care for migrant workers. Any approach will serve the middle belly.

    It is the extremes that will spell the difference between control and persistence of a disease in populations.

    Dr Manjula Datta
    Senior Consultant Epidemiology
    Forum for TB research
    Email: manjulad@yahoo.com

    ReplyDelete
  30. Fred Mwansa19 July, 2011

    Government committed is the best of resolving this problem in all sector of life, because they are the main provider of the services. This because of the tax we pay every day. Let us fight for this and their commitment and political will. Advocacy is the key to this factor.

    Fred Mwansa
    Email: fredmwansa@yahoo.ca

    ReplyDelete
  31. Rusli Ismail, Malaysia19 July, 2011

    Sometimes I feel that some of us are so detached from the patients and their problems so much so that they do not feel comfortable to come to us to seek help until it is very late.

    Rusli Ismail, Malaysia
    Email: isrusli@kb.usm.my

    ReplyDelete
  32. Aamir Siddiqui, UAE19 July, 2011

    Think TB! I don't think all healthcare providers of varying specialities think tuberculosis - that is why we often miss extrapulmonary TB.

    Aamir Siddiqui, UAE

    ReplyDelete
  33. Rusli Ismail, Malaysia20 July, 2011

    This, I think is a common problem. Most people in the governments are doing it because it is a job, just a job. Many don't feel obliged to go the extra mile to improve things. They have a long list of jobs they have to do to satisfy the bosses.

    Contract workers on the other hand may show greater commitment because their job depends on it. But all in all, it is not easy. Many volunteers like ourselves are sometimes overwhelmed by our primary responsibilities which may have nothing to do with this subject matter.

    Rusli Ismail, Malaysia
    Email: isrusli@kb.usm.my

    ReplyDelete
  34. Eric Aborgah20 July, 2011

    Infection Control in TB laboratories is a real conundrum, especially engineering infection control. Generally, there is poor standardization with respect to implementation of engineering infection control measures.

    For instance, a clear-cut consensus on ducting of BSCs needs to be documented and communicated. The classes of BSCs that are ductable and non-ductable need to be clearly differentiated from the engineering standpoint. These clarifications, if well established and communicated will greatly improve safety and guarantee the health security of laboratory personnel. The uncertainty surrounding the safety in the laboratory will thus be removed.

    Eric Aborgah, Ghana
    Email: eraborgah@yahoo.com

    ReplyDelete
  35. Shobha Shukla20 July, 2011

    It is not uncommon for TB patients to stop treatment midway, once they start feeling better, especially those who are poor/uneducated. There must be some patient friendly methods, which the government needs to incorporate in its RNTCP Programmes to address this serious issue.

    Shobha Shukla, India
    Email: shobha@citizen-news.org

    ReplyDelete
  36. Dr Muherman Harun, Indonesia21 July, 2011

    TUBERCULOSIS CAN BE CURED. THE PATIENT'S LIFE DEPENDS ON YOU.

    We already have a complete and comprehensive set of rules and regulations for implementing our TB program.

    But do we have a little empathy? It means so much especially for the poor and the needy.

    Without it, the Program will not flourish.

    Service without empathy is like serving a meal without salt.

    It is worth remembering Sir John Crofton's summary in his world famous book Clinical Tuberculosis. The book was translated in 16 different languages and distributed in 125 countries. He wrote: Tuberculosis can be cured. THE PATIENT'S LIFE DEPENDS ON YOU.

    Dr Muherman Harun
    St Carolus TB Program, Jakarta, Indonesia
    Email: muhermanharun@gmail.com

    ReplyDelete
  37. Dr Shanta Ghatak, India21 July, 2011

    This has come to my notice during a review meeting and where NO action was initiated... IV drug users, suffering from TB are using their used plastic bodied syringes as cooking fuel in domestic set ups!

    Considering this issue two levels need to be present in such forums in
    addition to the officers:

    1) Someone with a certain level of knowledge regarding the rights of these patients - preferably from such community and

    2) Environment/pollution awareness generating human resource

    Dr Shanta Ghatak, India
    Email: drshantaghatak@gmail.com

    ReplyDelete