The seventh paper in the Lancet Series on Tuberculosis shows how health system bottlenecks are impeding global efforts to control tuberculosis. Rapid introduction of suboptimum health system reforms have undermined tuberculosis control in many settings. Whereas, strengthening of TB control and concurrent financing and service access innovations have been associated with improved performance. It is written by Professor Rifat Atun, Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland, and Imperial College London, UK, and colleagues from WHO, Tanzania and Cambodia.
The authors say: "National tuberculosis programmes have been instrumental in global efforts to control tuberculosis. But bottlenecks in health systems related to financing, the workforce, and supply chain management have hampered progress towards national targets and Millennium Development Goals, despite increases in external funding. Rapidly introduced health-system reforms and suboptimum system designs have adversely affected national efforts to control tuberculosis in Africa, Latin America, and eastern Europe. Early and full case detection is a major challenge, and frequency of treatment success is low in many African and eastern European countries."
But there have been positive examples from a number of countries. Bangladesh, Cambodia, India, Tanzania, Thailand, and Vietnam, show innovative solutions for disease control and system design to address bottlenecks in health systems. Bangladesh has fostered involvement of non-governmental organisations in tuberculosis control to scale up services. Tanzania has expanded access by including tuberculosis services into primary care and using private sector and community health worker capacity, while Thailand expanded tuberculosis services by including them within its universal health coverage plan. The authors say: "Tuberculosis services have been integrated into primary health care, and are functioning with good outcomes. Participation of non-governmental organisations and the private sector has [been critical for] expanded access."
The authors point out that each country will require a solution specific to its own TB epidemic, with the national health system and the partners involved. But they show that the evidence on these solutions, which the countries can draw on, remains appallingly weak. They say: "No one size fits all. These highly varied responses need to be documented and compared to develop evidence-based policies and practice."
They say: "Despite increased financing for disease control, weak health systems are impeding global efforts to achieve tuberculosis targets and other health MDGs," adding*: "To target the complex and dynamic nature of the tuberculosis epidemic, the overlapping HIV epidemic, and emerging drug resistance, we need radical innovations to strengthen health systems and disease control. More of the same just won't do."
They conclude: "Evidence to support which strategies will and will not work in specific contexts remains weak... As efforts to strengthen health systems are intensified to reach MDGs and address threats to health security, such as tuberculosis and HIV, this evidence will prove crucial," adding*: "But, we are far from understanding what works in different contexts."
Professor Rifat Atun, Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland, and Imperial College London, UK. E) Rifat.Atun@theglobalfund.org / r.atun@imperial.ac.uk
Diana Weil, Coordinator, Policy & Strategy, Stop TB Department, WHO. T) +41-22-791-3072 E) weild@who.int
For full Series paper 7, see: http://press.thelancet.com/tbsp7.pdf
Note to editors: *asterixed part of quote is direct from authors and not found in text of the paper
Journal
The Lancet