Leveraging Global Fund's investments to expand innovative public-private provider engagement in TB.

BACKGROUND: TB remains a significant global health threat, claiming 1.3 million lives annually. The COVID-19 pandemic disrupted progress in the global TB response. Most patients with TB initially seek care from private providers, whereas only a small proportion are engaged by national programmes. The Global Fund is the major international source of funding for TB responses and supports the scale-up of innovative private-public mix (PPM) models in TB. METHODS: We collected programmatic and financial data on TB from 11 priority countries implementing PPM activities. Country examples and trends in the budget of Global Fund grants were analysed. RESULTS: These countries account for 60% of the global TB burden and Global Fund TB portfolio. PPM contributed 29% of national TB notifications in 2022 (range: 8% to 49%). During 2021-2023, US$1.4 billion was allocated for TB and US$155 million (11%) for PPM, while PPM contributed to 35% of national TB notification targets. PPM budgets increased over time from US$43 million (2002 to 2014) to US$129 million (2024 to 2026). CONCLUSION: The Global Fund's investments facilitated the expansion of innovative PPM models, improved access, and enhanced TB responses. Our indicative analysis underscores the need for evidence-based planning, collaboration, and increased domestic investment to accelerate the end of TB.

CONTEXTE: La TB reste une menace importante pour la santé mondiale, faisant 1,3 million de morts chaque année. La pandémie de COVID-19 a perturbé les progrès de la riposte mondiale à la TB. La plupart des patients atteints de TB recherchent d'abord des soins auprès de prestataires privés, tandis que seule une petite proportion est engagée par des programmes nationaux. Le Fonds mondial est la principale source internationale de financement de la lutte contre la TB et soutient l'extension de modèles innovants de partenariats public-privé (PPM, pour l'anglais « public-private mix ¼) dans le domaine de la TB. MÉTHODES: Nous avons recueilli des données programmatiques et financières sur la TB dans 11 pays prioritaires mettant en œuvre des activités de PPM. Des exemples de pays et les tendances du budget des subventions du Fonds mondial ont été analysés. RÉSULTATS: Ces pays représentent 60% de la charge mondiale de morbidité de la TB et du portefeuille du Fonds mondial de lutte contre la TB. La PPM a contribué à 29% des notifications nationales de TB en 2022 (fourchette : 8­49%). Au cours de la période 2021­2023, 1,4 milliard de dollars US ont été alloués à la TB et 155 millions de dollars US (11%) à la PPM, tandis que la PPM a contribué à 35% des cibles nationales de notification de la TB. Les budgets PPM ont augmenté au fil du temps, passant de 43 millions de dollars US (2002 à 2014) à 129 millions de dollars américains (2024 à 2026). CONCLUSION: Les investissements du Fonds mondial ont facilité l'expansion de modèles PPM innovants, l'amélioration de l'accès et le renforcement des ripostes à la TB. Notre analyse indicative souligne la nécessité d'une planification fondée sur des données probantes, d'une collaboration et d'une augmentation des investissements nationaux pour accélérer l'éradication de la TB.

A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018.

BACKGROUND: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. METHODS: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. FINDINGS: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). CONCLUSION: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.

Enhancing tuberculosis case finding in Tanzania: implementation of a quality improvement initiative.

Tuberculosis (TB) is one of the major causes of morbidity and mortality in Tanzania. A quality improvement (QI) initiative was implemented by the National Tuberculosis Programme with support from The Global Fund to enhance TB case finding. The initiative involved identifying gaps in the quality of services, introducing tools, building capacity of health workers, and strengthening laboratory and referral services. The initiative was piloted at sub-national level and subsequently scaled-up nationally. Overall, 1280 health workers were trained, leading to an 81% cumulative increase in notified TB cases in the pilot region and 4000 additional TB cases notified nationally. The QI initiative could serve as a model for the improvement of TB case notification in other settings.

La tuberculose (TB) est une des causes majeures de morbidité et de mortalité en Tanzanie. Une initiative d'amélioration de la qualité (QI) en trois points a été mise en œuvre par le Programme National Tuberculose avec un soutien du Fonds Mondial pour améliorer la détection des cas de TB. L'initiative a impliqué l'identification des failles de qualité des services de TB, l'introduction d'outils, le renforcement des capacités du personnel de santé, le renforcement du laboratoire TB et des services de référence. L'initiative a été pilotée au niveau sous national et ensuite étendue au niveau national : 1280 personnels de santé ont été formés, la coordination de la QI a été renforcée et ceci a contribué à 81% de l'augmentation cumulée des cas de TB notifiés dans la région pilote et à la notification de 4000 cas de TB supplémentaires au niveau national. L'initiative QI pourrait servir de modèle pour améliorer la notification des cas de TB dans d'autres contextes.

La tuberculosis (TB) es una de las principales causas de morbilidad y mortalidad en Tanzanía. El Programa Nacional contra la Tuberculosis introdujo, con el apoyo del Fondo Mundial, una iniciativa triple de mejoramiento de la calidad (QI) encaminada a reforzar la búsqueda de casos de TB. La iniciativa comportaba el reconocimiento de las deficiencias en la calidad de los servicios de TB, la introducción de instrumentos, el fortalecimiento de la capacidad de los trabajadores de salud y el refuerzo de los laboratorios de TB y los servicios de remisiones. Después de un ensayo piloto a escala subnacional, se amplió la iniciativa a todo el país. Se capacitaron 1280 trabajadores de salud y se reforzó la coordinación de la QI, con lo cual se propició un aumento acumulado de 81% de los casos de TB notificados en la región piloto y la notificación de 4000 casos de TB adicionales a escala nacional. La iniciativa de QI podría servir como modelo para mejorar la notificación de casos de TB en otros entornos.

Performance-based technical support for drug-resistant TB responses: lessons from the Green Light Committee.

Drug-resistant tuberculosis (DR-TB) constitutes a global threat and a major contributor to deaths related to antimicrobial resistance. Despite progress in DR-TB detection and treatment over the last decade, huge gaps remain in treatment coverage, access to quality care and treatment outcome. Global Fund investments have been critical to scaling up the existing and new diagnostic tools, treatment coverage and people-centred service delivery. The United Nations General Assembly (UNGA) high-level meeting represents unprecedented opportunities to accelerate towards addressing DR-TB. Established in 2000 and funded by the Global Fund since 2009, the Green Light Committee (GLC) mechanism has evolved from project approval to providing demand-based technical assistance to countries to scale up response to DR-TB based on their need and priorities. Lessons learnt from the GLC mechanism over 10 years demonstrate that a result-based, systematic and accountable technical assistance model to support scale-up of DR-TB response is critically important. Meeting the UNGA declaration targets requires major scale-up of current efforts and new tools, and hence the need for predictable, consistent and sustained technical support to countries, including through the regional GLC mechanism. The application of the principles and processes of this model could be adapted and replicated to design a similar performance-based and quality-assured technical support mechanism.

Effectiveness of community-based directly observed treatment for tuberculosis in an urban setting in Tanzania: a randomised controlled trial.

SETTING: An urban district in Dar es Salaam city with a high tuberculosis (TB) caseload. OBJECTIVE: To evaluate the effectiveness of community-based direct observation of treatment (DOT) using guardians and former TB patients compared to hospital-based DOT in an urban setting in Tanzania. DESIGN: Unblinded randomised control trial conducted in five sites under operational conditions in Temeke district. No changes to existing treatment delivery were made other than randomisation. The main outcome measure was treatment success. Analysis was by intention to treat. FINDINGS: A total of 587 new tuberculosis patients were enrolled. Among enrolled patients, 260 were assigned to community-based DOT using guardians and former TB patients and 327 to health facility-based DOT. Both DOT options gave similar treatment outcomes. Treatment success rate among patients under community and health facility-based DOT were 85% and 83%, respectively (OR 1.17, 95%CI 0.75-1.83). CONCLUSION: Community-based DOT is as effective as health facility-based DOT and can achieve good treatment outcomes, even in countries with well functioning National Tuberculosis Programmes.

Knowledge of disease and treatment among tuberculosis patients in Mwanza, Tanzania.

SETTING: A health care facility based study in a rural and urban setting in Mwanza region, Tanzania. OBJECTIVE: To determine patients' general knowledge of tuberculosis (TB) and the management of the disease. DESIGN: From 7 May to 7 July 1998, 296 pulmonary tuberculosis patients were consecutively interviewed. The majority of the respondents (89%) were outpatients. Questions were based on Tanzanian National Tuberculosis Programme (NTP) treatment guidelines for teaching tuberculosis patients. RESULTS: When correct answers to five out of seven questions asked was regarded as satisfactory knowledge, only 30% of the study population had satisfactory knowledge of disease and treatment. Persons with information on TB prior to diagnosis and those with higher education were more likely to have satisfactory knowledge (OR 9.23 and 19.93; 95%CI 2.77-31.08 and 5.74-69.19, respectively). There was a negative correlation between the level of knowledge and patients' age (-r = 0.181, P = 0.01). Knowledge was not significantly affected by sex or area of residence. The two most important sources of information about TB were health workers and former TB patients. CONCLUSIONS: Using NTP guidelines as reference, a substantial number of patients interviewed in health facilities in the study period had an unsatisfactory knowledge of TB disease and its management. The study did identify factors associated with satisfactory knowledge that could assist in designing health education intervention strategies.

Delay in tuberculosis case-finding and treatment in Mwanza, Tanzania.

SETTING: Health facilities in Mwanza region, Tanzania. OBJECTIVE: To determine factors responsible for delay from onset of symptoms of pulmonary tuberculosis to initiation of treatment. DESIGN: A cross-sectional descriptive study of 296 smear-positive tuberculosis patients. Emphasis was given to periods between 1) onset of symptoms and first consultation to a health facility, and 2) reporting to a health facility and initiation of treatment. RESULTS: Mean total delay was 185 days (median 136), with nearly 90% of this being patient's delay. The mean health system delay was 23 days (median 15), with longer delays in rural health facilities. The mean patient's delay was 162 days (median 120). This delay was significantly longer in rural areas, for patients with lower level of education, for those who first visited a traditional healer, and for patients who had no information on tuberculosis prior to diagnosis. Only 15% of the patients reported to a health facility within 30 days of onset of symptoms. CONCLUSION: There are significant delays in case-finding in Mwanza, Tanzania, with prolonged patient's delay. Facilitation of utilisation of health services, raising awareness of the disease and incorporation of private practice into tuberculosis control could help to reduce these delays.