How to hinder tuberclosis control; five easy steps

July 2014 LSHTMBlog; Tuberculosis (TB) control remains an important global issue, with 8.6 million TB cases reported by the World Health Organization in 2012 and 1.3 million deaths from the disease. Over 95% of tuberculosis deaths occur in low-and-middle-income countries.

Writing in an article for The Lancet, the School’s Dr Mishal Khan and Professor Richard Coker argue that difficult decisions about resource allocation for TB control need to be made on the basis of evidence and long-term strategic goals: “Our historical failure to embed research findings into effective policies has meant that we have squandered opportunities and resources.”

They highlight five steps commonly taken by policy makers that could be impeding efforts to control TB:

  1. Incentivise national tuberculosis programmes to obscure rather than highlight programmatic challenges

Uniform targets for indicators, such as the tuberculosis treatment success rate (85%), are often set for national TB programmes. Dr Khan and Prof Coker write that “when jobs are at risk if targets are not met [as has been reported by some TB programme managers] there is little incentive for programmes to highlight challenges posed by patients dropping out during the lengthy tuberculosis treatment course, which is a major cause of the emergence of multidrug-resistant tuberculosis.”

They also highlight that international donors might introduce “perverse incentives” that affect reporting by national TB programmes. For example: “The Global Fund to Fight AIDS, Tuberculosis and Malaria uses a performance-based funding mechanism to decide which grants to renew… In other words, if reports do not show that targets are met, the programme loses funding for subsequent years.” Since renewal of funding is often dependent on maintaining a high treatment success rate in patients with multidrug-resistant TB, there is an incentive to avoid expansion of services to hard to treat groups of patients in case this leads to a drop in the overall rate of treatment success.

  1. Rush to medical or technological solutions rather than systems strengthening

Decision makers often allocate resources for control of multidrug-resistant TB on the basis of urgency to treat rather than evidence in support of long-term strategic goals. The authors argue that “this treatment-focused approach to the growing epidemic of multidrug-resistant tuberculosis is akin to allowing a running tap to flood a room while you mop up the water rather than switching the tap off.”

They believe that undue focus on treating an increasing number of patients with multidrug-resistant TB can reduce capacity to ensure adherence to TB treatment in most patients with drug-sensitive TB. Lower adherence to TB treatment is likely to exacerbate the emergence of multi-drug resistant TB; “thus a diversion of resources from drug-sensitive to drug-resistant tuberculosis, which occurs when the two are seen as separate problems, could in fact contribute to an increase in multidrug-resistant tuberculosis.”

  1. Focus on purchasing drugs for multidrug-resistant tuberculosis and ignore essential infrastructure requirements to deliver them effectively

Dr Khan and Prof Coker note that a series pitfall when funding is directed towards multidrug-resistant TB control is limiting financial support to cover only the costs of second-line TB drugs, and ignoring other essential costs such as setting up a locally appropriate treatment support system and training medical personnel.

“When funding is provided for second-line drugs but not for the many other additional costs, national tuberculosis programmes are forced to cut corners on elements that are important for ensuring patients’ adherence to treatment and for maintaining an effective system for managing the wider introduction of second-line drugs… Maintaining access to second-line drugs when systems that support and monitor treatment are inadequate is likely to expand the resistance profile of tuberculosis.”

  1. Leave the unregulated private sector to incorrectly dispense antimicrobials

A range of antimicrobials are readily available at pharmacies and local grocery shops in many low-and-middle-income countries. “The quality of the medicines is questionable, and usually no advice is given to patients about duration of treatment for anti-tuberculosis drugs. Patients can buy as many days of treatment as they can afford,” write the authors.

They also note that most patients in south and southeast Asia seek care in the private sector where they often receive incorrect antimicrobial treatment for TB.“Thus, conditions are ripe to generate multidrug-resistant tuberculosis, and potentially expand the resistance profile further.”

  1. Start and stop tuberculosis programme funding suddenly

Finally, the authors highlight that abruptly changing levels of funding for TB programmes can lead to interruptions in in TB treatment and promote a generation of drug resistance. They give the example of Médecins Sans Frontières’ activities in Myanmar (Burma), which were suspended in February 2014 resulting in about 3,000 TB patients being unable to access treatment. “Unfortunately, the threat of multidrug-resistant tuberculosis has increased as a result, particularly in the Rakhine state where health services are still suspended,” they write.

Concluding their article, Dr Khan and Prof Coker acknowledge that there are many challenges in formulating policies to best control TB, especially with limited resources. “However, history shows that acting on the basis of urgency or unfounded assumptions rather than evidence, and ignoring realities on the ground, such as perverse incentives and unregulated private practitioners, will lead to squandering of tuberculosis control efforts at best, and causing harm at worst…

“…We feel forced to ask whether, in another 30 years, we will look back and say that, despite our knowledge base and experience, we exacerbated the burden of tuberculosis because of our haste simply to act.”



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