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:: Box 6.4 Reforming systems to expand people-centred outpatient care in high MDR-TB burden countries in Europe MDR-TB poses a particular challenge in WHO’s European Region, which has nine of the world’s 30 high MDR-TB burden countries. For both patient-centered care and costeffectiveness, TB care is best delivered in the community. Nevertheless, many of these high MDR-TB-burden countries still provide substantial inpatient care for patients with drug-susceptible and drug-resistant TB (see Fig. B6.4.1 and Fig. B6.4.2). Some historical systems of institutional staffing, payment and reimbursement created perverse incentives in many settings to hospitalize patients unnecessarily, or for much longer periods than required. These incentives often persist. Also, for lack of resources (and insufficient capacity), outpatient and primary care services have been ill-prepared to provide adequate TB and MDR-TB treatment and care. Major challenges to enable greater outpatient care include developing appropriate, country-specific TB care delivery models; creating sustainable financing mechanisms for TB care; ensuring adequate human resources; and providing social protection for TB patients. With technical support, many of these countries are increasing their efforts to reduce hospitalization rates by improving patient-centred outpatient services, decreasing the number of TB beds and the unnecessarily long duration of hospital stays, reallocating TB budgets accordingly, and reassigning staff in hospitals to overall pulmonary and primary health care. In a concerted effort to support countries to face their MDR-TB challenge and the necessary reform of systems, the Center for Health Policies and Studies (PAS) and the WHO Regional Office for Europe (EURO) conceived the Tuberculosis Regional Eastern European and Central Asian Project (TB-REP), a which is funded by the Global Fund. The aim of TB-REP is to use a systems-based approach to improve TB treatment outcomes and accelerate progress in ending the epidemic by removing health system barriers and scaling up health system reforms. The project complements country TB-specific and broader health reform efforts supported by a http://www.pas.md/en/TBRep Continued :: FIG. B6.4.1 Hospitalization of drug-susceptible cases in the WHO European region, 2015 a Montenegro Bosnia and Herzegovina Czech Republic Slovenia Norway Armenia Slovakia Kazakhstan Romania Serbia Albania Switzerland Finland Uzbekistan Kyrgyzstan Republic of Moldova The Former Yugoslav Republic of Macedonia Russian Federation Estonia Tajikistan a Countries for which data are available. 65 65 63 67 67 80 80 80 80 78 78 85 85 90 90 98 98 95 95 95 Turkey 50 Sweden 50 Ireland 49 Georgia 30 Portugal 30 0 20 40 60 80 100 Percentage hospitalized :: FIG. B6.4.2 Hospitalization of M/XDR-TB cases in the WHO European region, 2015 a Armenia Czech Republic Serbia Russian Federation Slovakia Tajikistan Montenegro Bosnia and Herzegovina The Former Yugoslav Republic of Macedonia Republic of Moldova Georgia Romania Netherlands Kazakhstan Kyrgyzstan Sweden Portugal Estonia Switzerland Turkey Finland Norway a Countries for which data are available. 30 28 50 45 70 70 60 90 90 85 82 120 150 144 180 180 180 210 200 240 240 240 0 50 100 150 200 250 Average length of hospitalization (days) GLOBAL <strong>TUBERCULOSIS</strong> REPORT 2016 :: 99
Box 6.4 continued USAID, the World Bank and the German governmentowned development bank, KfW, among others. It enables intercountry activities involving 11 eastern European and central Asian countries b for the coming four years. Among the aims are minimizing TB patient hospitalization rates and average lengths of hospital stay by shifting resources towards more people-centred care, including outpatient services, and supporting other costeffective solutions to local challenges. The countries involved in TB-REP will be supported by PAS, as principal recipient for the project, WHO/ EURO and other partners, including the TB Europe Coalition, the European Respiratory Society, the London School of Economics and Political Science, the London School of Hygiene and Tropical Medicine, and the Stop TB Partnership. Work will include analytic reviews, documentation and adaptation of good practices, operational research, development of human resources for health, capacity-building, advocacy and civil society engagement. b The 11 countries addressed in TB-REP are Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. End TB Strategy: the essentials. 1 These pointers include assessing needs; building collaboration with social protection counterparts; determining clear terms of eligibility; making informed decision on interventions and level of support; enabling sustainable funding; and improving management, monitoring, evaluation and research. There is some consensus that MDR-TB patients and low-income or undernourished patients with drug-susceptible TB should probably have higher priority than other TB patients for social protection resources. WHO guidance on the role of nutritional care and support for TB patients suggests there is a need to more effectively differentiate nutritional need and economic needs in deciding on support. 2 Updated WHO TB treatment guidelines now in development include a review of the evidence to determine which patient support interventions have a documented impact on treatment outcomes. Their impact on the cost burden faced by patients will not be covered in this guidance. In conclusion, social support for TB patients must become more efficient and sustainable. National TB programmes (NTPs), working with health and social sector partners and nongovernmental organizations (NGOs), can enable patient support to move from a project-based 1 World Health Organization. Implementing the End TB Strategy: the essentials. Geneva: WHO, 2015 (http://www.who.int/tb/ publications/2015/end_tb_essential.pdf?ua=1, accessed 6 September 2016). 2 World Health Organization. Guideline: nutritional care and support for patients with tuberculosis. Geneva: WHO; 2014 (http://apps.who.int/ iris/bitstream/10665/94836/1/9789241506410_eng.pdf, accessed 5 September 2016). approach to a programmatic one, integrated with larger platforms. Good practices depend on context, but opportunities exist in many high TB burden countries to extend the reach, depth and impact of social protection for those in need and for TB prevention overall. 6.5 Assessing the total costs borne by TB patients and determining the occurrence of catastrophic total costs due to TB To inform policy and practices for improved social protection of TB patients and affected households, and to reach the 2020 target of eliminating catastrophic costs for TB TB-affected households, 3 WHO is supporting countries to design, implement and analyse TB patient cost surveys. In 2015, the WHO Global TB Programme worked with a task force of experts to develop a field-testing version of a standardized methodology for this work, and produced a questionnaire and protocol for country adaptation. The nationally representative patient surveys have both primary and secondary objectives. The primary objectives are: ■ To document costs and identify the main cost drivers to inform policy. ■ To monitor progress towards the End TB Strategy target that no (zero per cent) of TB-affected households face catastrophic total costs due to TB. The secondary objectives are: ■ To enable subgroup analyses (e.g. for drug-susceptible TB and MDR-TB separately, and analyses by socioeconomic status, sex, and location such as urban or rural). ■ To determine the association between costs and treatment outcome (using routine cohort data). A key indicator that can be derived from a survey is the proportion of patients with catastrophic total costs due to TB. This is defined for operational purposes as the number of TB patients (and their households) who experience catastrophic total costs divided by the number of all TB patients treated in the NTP network. Catastrophic total costs is defined as total costs (indirect and direct combined) incurred during illness and treatment that exceed a given threshold (e.g. 20%) of the household’s annual income. The numerator is the total direct and indirect costs incurred from the onset of symptoms to the end of TB treatment for the household, and the denominator is annual household income. This TB-specific indicator of catastrophic total costs is distinct from the indicator that WHO uses to measure financial protection. WHO uses the share of the population incurring “catastrophic expenditures”, which, as noted above, refers to OOP expenditures for health care (for all 3 Lonnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Beyond UHC: monitoring health and social protection coverage in the context of tuberculosis care and prevention. PLoS Med. 2014;11(9):e1001693 (https://www.ncbi.nlm.nih.gov/ pubmed/25243782, accessed 5 September 2016). 100 :: GLOBAL <strong>TUBERCULOSIS</strong> REPORT 2016
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GLOBAL REPORT TUBERCULOSIS 2016
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WHO Library Cataloguing-in-Publicat
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:: Abbreviations aDSM AE AIDS ART A
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The principal source of financial s
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Zhumagali Ismailov, Sarah Jackson,
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:: Executive Summary Background The
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TB prevention services South Africa
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Chapter 1 :: Introduction Tuberculo
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:: Box 2.1 The Sustainable Developm
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:: Box 2.3 The End TB Strategy at a
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:: TABLE 2.1 Top 10 indicators (not
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TABLE 2.2 :: The three TB high-burd
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Chapter 3 :: TB disease burden :: K
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:: Box 3.1 The WHO Global Task Forc
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:: Box 3.2 Updates to estimates of
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:: Box 3.3 Updated and interim esti
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:: FIG. 3.1 Strengthening national
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:: TABLE 3.2 Estimated epidemiologi
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:: FIG. 3.3 Estimated TB incidence
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:: FIG. 3.5 Global trends in the es
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:: FIG. 3.8 Trends in estimated TB
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:: FIG. 3.10a Top causes of death w
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:: FIG. 3.14 Trends in estimated TB
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:: FIG. 3.16 Data sources available
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:: TABLE 3.5 Estimated incidence of
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:: FIG. 3.20 Estimated incidence of
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:: FIG. 3.22 Global progress in imp
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:: TABLE 3.6 Number of TB cases fou
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:: TABLE 3.7 HIV-negative and HIV-p
Page 60 and 61: :: FIG. 3.29a The prevalence:notifi
Page 62 and 63: :: FIG. 3.31b The average CFR by st
Page 64 and 65: SIM and SINAN case-based databases,
Page 66 and 67: Prompt and accurate diagnosis of tu
Page 68 and 69: :: FIG. 4.2 New and relapse TB case
Page 70 and 71: :: FIG. 4.5 Percentage of new and r
Page 72 and 73: :: FIG. 4.8 Global numbers of notif
Page 74 and 75: :: TABLE 4.4 National guidance in p
Page 76 and 77: :: FIG. 4.9 Percentage of bacteriol
Page 78 and 79: :: FIG. 4.12 Number of MDR/RR-TB ca
Page 80 and 81: :: FIG. 4.14 Case notification rate
Page 82 and 83: :: FIG. 4.16a The ten countries wit
Page 84 and 85: :: Box 4.5 Community contributions
Page 86 and 87: :: FIG. 4.18 Estimated ART treatmen
Page 88 and 89: issued in March 2013 and updated in
Page 90 and 91: :: FIG. 4.22 Treatment outcomes for
Page 92 and 93: :: Box 4.6 Active TB drug-safety mo
Page 94 and 95: Prevention of new infections of Myc
Page 96 and 97: :: TABLE 5.2 TB preventive treatmen
Page 98 and 99: :: TABLE 5.3 Provision of TB preven
Page 100 and 101: :: FIG. 5.5 Coverage of BCG vaccina
Page 102 and 103: This chapter aims to provide a tube
Page 104 and 105: :: FIG. 6.2 Government spending on
Page 106 and 107: :: Box 6.1 Implications for TB of e
Page 108 and 109: :: Box 6.2 Innovations in engaging
Page 112 and 113: :: TABLE 6.1 TB patient social supp
Page 114 and 115: :: FIG. 6.5 Surveys of costs faced
Page 116 and 117: :: TABLE 6.3 Status of selected SDG
Page 118 and 119: Continue current trend (base case s
Page 120 and 121: can provide insights into progress
Page 122 and 123: lion, most (US$ 4.4 billion, 67%) i
Page 124 and 125: :: Box 3.2 Updates to estimates of
Page 126 and 127: :: FIG. 7.5 Funding for NTP budgets
Page 128 and 129: :: Box 7.2 International donor fund
Page 130 and 131: :: FIG. 7.6 Reported funding gaps f
Page 132 and 133: :: Box 7.3 Methods used to estimate
Page 134 and 135: :: Box 8.1 WHO’s Global Action Fr
Page 136 and 137: is critical to allow for the time-s
Page 138 and 139: :: FIG. 8.2 The global development
Page 140 and 141: :: FIG. 8.3 The development pipelin
Page 142: Annex 1 Access to the WHO global TB
Page 145 and 146: A data dictionary that defines each
Page 147: Annex 2 Country profiles :: FOR 30
Page 150 and 151: Bangladesh population 2015 :: 161 m
Page 152 and 153: China population 2015 :: 1 376 mill
Page 154 and 155: Democratic Republic of the Congo po
Page 156 and 157: India population 2015 :: 1 311 mill
Page 158 and 159: Kenya population 2015 :: 46 million
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Myanmar population 2015 :: 54 milli
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Pakistan population 2015 :: 189 mil
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Russian Federation population 2015
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Thailand population 2015 :: 68 mill
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Viet Nam population 2015 :: 93 mill
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Central African Republic population
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Lesotho population 2015 :: 2.1 mill
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Namibia population 2015 :: 2.5 mill
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Sierra Leone population 2015 :: 6.5
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Zimbabwe population 2015 :: 16 mill
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WHO African Region WHO MEMBER STATE
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WHO Eastern Mediterranean Region WH
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WHO South-East Asia Region WHO MEMB
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Annex 4 TB burden estimates, notifi
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:: TABLE A4.1 TB incidence estimate
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:: TABLE A4.1 Table TB incidence A4
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:: Table TABLE A4.2 A4.2 Estimates
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Table :: TABLE A4.2 A4.2 Estimates
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:: TABLE A4.3 Measured percentage o
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:: TABLE A4.3 Measured Table A4.3 p
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:: TABLE A4.4 TB case notifications
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:: TABLE A4.4 TB case notifications
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:: TABLE A4.5 Treatment outcomes by
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:: TABLE A4.5 Treatment outcomes by
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ISBN 9 789241 565394 Ending TB by 2
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