Is it worthwhile to decentralize drug-resistant TB services?

Alice Sagwidza-Tembe, CNS Correspondent, Swaziland
Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) are global challenges. Treatment of both requires prolonged and toxic therapies. Centralised inpatient treatment, delivered by specialist doctors and nurses in a specialised hospital, is still a common practice in many MDR-TB high-burden countries.

But the lack of hospitals, long waiting lists for admissions, and high hospitalisation costs present challenges.

Decentralised care on the other hand is located in the local community in which the patient resides - community health centres, clinics, religious and other community venues, patient’s home or workplace— and may include a brief period of initial hospitalization. It is delivered mainly by trained volunteers, community nurses or non-specialised doctors.

So, is decentralized treatment and care for MDR-TB patients to be preferred over the centralised one in terms of leading to improved treatment success rate, better treatment adherence and reduced patient and health service costs? Well, judged by deliberations at the just concluded 47th Union World Conference on Lung Health in Liverpool, the answer is an overwhelming YES.

Countries, like Swaziland, South Africa, Uganda, Peru and Ethiopia shared their experiences of decentralisation of MDR-TB treatment services.

Roadmap to guide decentralisation is key

Granting that any new approach does come with its own excitement and challenges, it was clear that all countries need to define a clear roadmap to guide decentralisation of MDR-TB services, as it is not a ‘one size fit all’ situation. But broadly speaking, all countries did begin with the following:

Assessment of the current outcomes of the in-patient model

In Ethiopia, the ambulatory care model was introduced in 2012. Before 2012, limited diagnostic and treatment facilities were available for MDR-TB patients. The country had only 2 treatment initiation sites in 2011, to which patients had to travel long distances (sometimes as long as about 800 km) just to get a diagnosis. The process of decentralisation saw the number of treatment initiation sites grow to 48 by 2016, with another 658 treatment follow-up centres and no patients on the waiting list. Patient enrolment increased to 9218 in 2016 from 553 presumptive MDR-TB patients in 2012; and MDR-TB patients ever enrolled increased from 56 to 1005. MDR-TB treatment success rate rose from 59% in 2011 to 70% in 2016.

In Uganda there was an increase from 13 to 112 GeneXpert machine-equipped sites between 2010 and 2015, resulting in 80% treatment success rate and 55% cure rate among MDR-TB patients.

Improved continuity of care

Dr Nobert Ndjeka, Director in the Department of Health in South Africa, said that South Africa’s success with patient-centred decentralisation of services also recorded increased access to MDR-TB care services, reduced time to MDR-TB treatment initiation; improved continuity of care and clinical outcomes; and huge savings in costs. The number of MDR-TB treatment initiation sites increased from 17 in 2011 to 648 in 2016. Also, there was a marked improvement in treatment success rate during this period - for MDR-TB it increased from 49% to 53% and for XDR-TB from 25% to 31%.

In Swaziland community-based model is becoming more common over the years. 50% of the patients were followed in community-care in 2013. Results have been astounding - higher treatment success rate of 76% in community care as against 68% in clinic care; fewer deaths at 15% in community care as against 68% in clinic care. There was low loss to follow up for patients provided with full support package—like food vouchers and transport allowance. Cost per patient in community care was cheaper by $355.

Peru’s experience, as shared by the National TB Coordinator, Dr Guizado, pointed to several benefits of the nationwide decentralization of MDR-TB treatment at primary health care level since 2012. Only MDR-TB patients with complications and XDR-TB patients are hospitalized at the beginning of the first phase of treatment and provided follow up treatment at home with appropriate infection control measures and strong daily nurse support to ensure DOT. There is universal access to rapid testing for MDR- TB for all TB patients, and social protection through comprehensive health insurance funded by the Peruvian government.

Apart from these country specific sharing of experiences, a a systematic review of 8 controlled studies comprising 4493 MDR-TB patients done by Greg Fox from University of Sydney also found that treatment success for MDR-TB patients improved when patients were treated in a decentralised setting, when compared to a centralised setting.

Assessment of MDR-TB Programmatic management approach

To be able to manage the expansion and growing demand for services, all the countries shared that they had to go back to the National TB Control Programme Strategic Plans, review WHO guidelines and adapt to country health systems. This led to the development of new aids and patient education materials.

Assessment of health practitioner’s skills and tools for implementation: Countries generally experienced high rates of staff turnover, which incurred high cost and time to train and retrain staff. Dr Welile Sikhondze, Technical Advisor and Research Coordinator at the National TB Control Programme Swaziland, added that it is even difficult to give incentive and invest in the staff as they rotate every six months. This was slightly different from other countries like South Africa where it is understood that the health practitioners are already paid and this is their work. Other concerns on incentives for healthcare practitioners were up-scalability and sustainability of such an investment. To say the least, this is likely to isolate the healthcare workers managing TB from other disease department— the silo approach which is being fought against.

Expansion of diagnostic equipment and medical skills: It was the same cry by all countries that there is limited equipment to go around and even when it is there, there seem to be limited qualified people to interpret test results, including audiology and ECG test results. Further, while adverse effects are getting to be less with the new drugs and shorter treatment regimes, there are still there. So far, the main recourse is aggressive pharmacological intervention, and hence the need to improve procurement and stock management systems.

Systematic monitoring: As shared by Dr Degu Jerene, a public health expert from Ethiopia, as decentralisation was rolled out in the country, there was close supervision of the peripheral sites to ensure quality of care and infection control. Further, skills to engage in new approaches, data records and systematic reviews need to be incorporated to record good practices for scale up and adoption in other similar settings. Also, countries must record and compare the outcomes of the new home based and ambulatory model with the old inpatient model including, but not limited to, (i) Cost to patient, hospital, health care workers and the community; (ii) Quality of the care maintenance; (iii) Record good practices for scale up and adoption in other similar settings.

Perhaps WHO recommended ambulatory models of care and treatment need to replace hospital-based models as they are likely to lead to Improved treatment success rate, Better treatment adherence and Reduced patient and health service costs. Community based care coupled with treatment support packages can overcome access and treatment adherence barriers for rural communities.

As noted in most African states cohort studies, social support services are not that strong and MDR-TB is putting a spotlight on it as well as depends on it for favourable outcomes. This begs the question: Are National TB Programmes responsible for eradicating poverty? and that is a discussion for another day.

Alice Sagwidza-Tembe, CNS Correspondent, Swaziland
30 October 2016
(Alice Tembe is providing thematic coverage from the 47th Union World Conference on Lung Health in Liverpool, UK, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @Tembe3)

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