Third-Party Evaluation of the National Tuberculosis Control Programme – NTP Findings, Conclusions and Recommendations
1
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
AUTHORS OF THIS REPORT Dr. Syed Arif Hussain
Health System Specialist, TRF
Dr. Eric Donelli
International Team Leader, HLSP
Dr. Sarwat Karam Shah
Research Associate, HLSP
Ms. Pauline Scheelbeek
Epidemiologist, HLSP – Royal Tropical Institute
Mr Sher Shah Khan
Finance Specialist, HLSP
Dr. Sang Jae Kim
Laboratory Specialist
Mr. Jurgen Hulst
Health Logistics Specialist,
Dr. Tariq Rehim
Managing Director, RH-Aid
Dr. Ali Yawar Alam
Epidemiologist and M&E Specialist, RH-AID
Right & Health-Alliance for Integrated Development (RH-Aid) conducted the Health Facility and Household survey For information on this report please address your correspondence to:
[email protected] Copyright: Technical Resource Facility – TRF/HLSP House No. 5B, Street 1, F 7/3 Phone: +92-51-2610-934/935 Fax: +92-51-8316-362 Islamabad - Pakistan
DISCLAIMER This document is issued for the party which commissioned it and for specific purposes connected with the above-captioned project only. It should not be relied upon by any other party or used for any other purpose. We accept no responsibility for the consequences of this document being relied upon by any other party, or being used for any other purpose, or containing any error or omission which is due to an error or omission in data supplied to us by other parties.
i
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
ACKNOWLEDGEMENTS This evaluation would not have been possible had it not been for the immense kindness and hospitality of the many Pakistanis who shared their opinions and experiences with Consultant Team members in relation to the NTP programme. An evaluation of this size can only succeed through team effort. We thank all those, in and outside Pakistan, who volunteered, contributing their time and views to assist in our evaluation, whether as key informants or interviewees. The CT acknowledgements are random and no part of the list is secondary to any other. From the group who closely supervised the evaluation study, we wish to thank Dr. Raza Zaidi, Health and Population Adviser at the UK Department for International Development (DFID), for providing financial and personal support to the study team and Dr. Qaiser Pasha, at the Australian Agency for International Development (AusAID), for personal support to the study team. At the Technical Resource Facility (TRF) in Islamabad, we are indebted to Dr. Syed Arif Hussain and Dr. Nasir Idrees,
Health
System
Specialists
TRF,
who
personally
oversaw
the
implementation of this evaluation (well done and huge thanks from the team) and to Mr. Farooq Azam, Team Leader at the TRF, for his continued advice and support. At RH-AID, we would like to thank Dr. Tariq Rahim, Managing Director at RH-AID, for allowing a good deal of flexibility and time and acting as the team leader in the data collection in KPK and GB; Dr. Ali Yawar Alam, epidemiologist and M&E specialist, RH-Aid; Ms. Adila Khan for logistics and translations of tools; Mr. Waqas Bokhari for logistic and data management and helping to coordinate with the pretesting and data collection phases. Warm thanks go to the district teams and their team leaders namely, Dr. Fozia Khan-Punjab; Dr. Ghulam Haider Akhund-Sindh; Dr. Tahira Kamal Umrani-Baluchistan and Dr. Shaza Ali Khan for AJK, Islamabad and Punjab, who conducted the survey in the field, sometimes in difficult circumstances. At the NTP, MoH, we are especially indebted to Dr. Abrar Ahmad Chughtai, National Programme Officer, for his invaluable support and collaboration during all TPE phases and in all aspects of this exercise. Without his constant help and availability, this report would have not been possible. Dr. Sabira Tahseen, the National Coordinator for the National TB Reference Laboratory, provided invaluable
ii
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
insight. At HLSP, we are indebted to Claire Sanders, for holding the evaluation budget strings so efficiently, Taher Moghim and Jack Eldon. The Technical Review Panel helped the evaluation team review the study methodology and approach, the original design and then the first drafts of the report. The panel comprises Dr. Abdul Ghafoor, Country Coordinator KNVC, Dr. Rehan Hafrez and Dr. Amal Bassili, WHO EMRO. In the provinces, we had full support and collaboration from the PTP-TB coordinators and their teams namely, Dr. Ismat Ara in Sindh; Dr. Darakhshan Bader in Punjab; Dr. Abdulla Khaliq in FATA; Dr. Abdulla Latif in KPK; Dr. Abdulla Mobin in GB; Dr. Sahabir Ahmed in AJK and Dr. Monir Raeesani Baluchistan, with whom we exchanged opinions, experiences, and future concerns. We are profoundly grateful to all those who contributed, especially in the communities. We dedicate this report to them, to the millions of Pakistani people who deserve better access to basic health care and in particular, to TB control.
iii
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
CONTENTS ABBREVIATIONS AND ACRONYMS ................................................................... 1 EXECUTIVE SUMMARY ....................................................................................... 2 1.
2.
3.
INTRODUCTION........................................................................................... 13 1.1
Report Structure ..................................................................................... 13
1.2
Context .................................................................................................. 14
1.3
Background to the Evaluation ................................................................ 15
1.4
Evaluation Purpose and Objectives ........................................................ 16
1.5
Management and Reporting ................................................................... 17
1.6
Study Approach and Methodology ......................................................... 18
1.7
Independence and Quality ..................................................................... 23
BACKGROUND OF THE NTP ...................................................................... 26 2.1
Evolution of the Programme ................................................................... 26
2.2
Program Objectives, Targets and Strategies .......................................... 31
2.3
Inter-Sectoral Collaboration and Partners .............................................. 34
2.4
Monitoring and Supervision System ....................................................... 41
2.5
Epidemiological Situation at National and Sub-National Level (2010)..... 42
MAJOR FINDINGS ....................................................................................... 48 3.1
Financial Management (FM) .................................................................. 48
3.1.1
Introduction ....................................................................................................... 48
3.1.2
Overview and Analysis for 2005 - 2010 ............................................................ 49
3.1.3
Fund Flow ......................................................................................................... 54
3.1.4
Programme Financial Expenditure ................................................................... 58
3.1.5
Trend Analysis .................................................................................................. 63
3.1.6
Programme Financial Management Capacity .................................................. 68
3.1.7
Contextual Analysis – Change and PFM Challenges ....................................... 70
3.1.8
Monitoring & Evaluation .................................................................................... 72
3.1.9
Key Findings ..................................................................................................... 75
3.2
Procurement and Supply Chain Management ........................................ 79
3.2.1
Overview 2005-2010......................................................................................... 80
iv
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
3.2.2
Findings ............................................................................................................ 85
3.2.3
Selection ........................................................................................................... 86
3.2.4
Quality Assurance ............................................................................................. 87
3.2.5
Forecasting ....................................................................................................... 88
3.2.6
Procurement ..................................................................................................... 90
3.2.7
Storage and Distribution ................................................................................... 94
3.2.8
Monitoring, Evaluation & Management Capacity ............................................. 99
3.3
Human Resources Management .......................................................... 100
3.3.1
Introduction ..................................................................................................... 100
3.3.2
Methodology ................................................................................................... 101
3.3.3
Key Findings – HR Management Capacity..................................................... 105
3.3.4
Trainings ......................................................................................................... 107
3.3.5
Key Findings - Trainings ................................................................................. 112
3.4
Diagnostic and Laboratory Services ..................................................... 113
3.4.1
Introduction ..................................................................................................... 113
3.4.2
Overview TB Laboratory Services 2000/2005-2010 ....................................... 115
3.4.3
Laboratory Services for Diagnosis of Smear Negative and MDR TB Cases ........................................................................................................................129
3.4.4
National TB Reference Laboratory (NTRL) .................................................... 130
3.4.5
Monitoring and Evaluation .............................................................................. 132
3.5
Service Delivery ................................................................................... 134
3.5.1
Treatment Outcome ........................................................................................ 135
3.5.2
Treatment Regimens and Direct Observation of Treatment (DOT)................ 139
3.5.3
Findings at Federal and Provincial Levels ...................................................... 142
3.5.4
Findings at District and Field Levels ............................................................... 144
3.5.5
Other Service Delivery Entities ....................................................................... 152
3.6
Operational Research .......................................................................... 156
3.6.1
Introduction ..................................................................................................... 156
3.6.2
Methodology ................................................................................................... 157
3.7
Advocacy, Communication & Social Mobilisation (ACSM) ................... 159
3.7.1
Understanding ACSM ..................................................................................... 159
3.7.2
From IEC to BCC to ACSM: A Decade of Transformation ............................. 160
3.7.3
ACSM Activities at a Glance: The “National Strategies and Operational
Guidelines 2008”......................................................................................................... 162 3.7.4
Monitoring and Evaluation: The “National Monitoring and Evaluation
Framework 2008”........................................................................................................ 164 3.7.5
TPE Findings .................................................................................................. 164
3.7.6
Findings at Federal and Provincial Level ........................................................ 168
v
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
3.7.7
Findings at District and Field Level: Community Based Interviews – TB Client
Interviews (Data Collected By RH-AID) ...................................................................... 169
4.
5.
6.
CONCLUSIONS.......................................................................................... 177 4.1
Financial Management ......................................................................... 178
4.2
Procurement and Supply Chain Management ...................................... 180
4.3
Human Resources ............................................................................... 182
4.4
Diagnostic and Laboratory Services ..................................................... 184
4.5
Service Delivery ................................................................................... 186
4.6
Operational Research .......................................................................... 189
4.7
Advocacy Communication and Social Mobilisation ............................... 191
RECOMMENDATIONS ............................................................................... 193 5.1
Financial Management: Risk Mitigating Strategy and Action Plan ........ 193
5.2
Procurement and Supply Chain Management ...................................... 194
5.3
Human Resources ............................................................................... 197
5.4
Diagnostic and Laboratory Services ..................................................... 199
5.5
Service Delivery ................................................................................... 200
5.6
Operational Research .......................................................................... 203
5.7
Advocacy Communication Social Mobilisation ...................................... 203
ANNEXES................................................................................................... 206
ANNEX A: CORE DOCUMENTS ....................................................................... 206 ANNEX B: PERSONS CONSULTED ................................................................ 209 ANNEX C: MISSION TOR ................................................................................. 213 Number & Break Down of Consultancy Days .................................................. 222 ANNEX D: NTP ORGANOGRAM ...................................................................... 226
vi
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
ABBREVIATIONS AND ACRONYMS ACS M AJK ANC AIDS
Advocacy Communication and Social Mobilisation Azad Jammu and Kashmir Antenatal Care Acquired Immunodeficiency Syndrome Behaviour Change Communication Basic Health Unit Community Based Organisation Case Detection Rate Canadian International Development Agency Case Fatality Rate
KP
Khyber Pakhtunkhwa
LFA LHW MC
Local Fund Agency Lady Health Workers Mercy Corp
M&E M&S MDG MDR-TB MCH
Monitoring and Evaluation Monitoring and Supervision Millennium Development Goal Multi-Drug Resistant Tuberculosis Maternal and Child Health
MNCH
Consultant Team District Government District Department of Health
MoH MOU NA
Maternal, Neonatal and Child Health Ministry of Health Memorandum of Understanding Northern Areas
NGO
Non-Governmental Organisation
DHO DoH
Department of International Development District Health Office Department of Health
NSP NWFP
DOT
Directly Observed Treatment
NHP
National Strategic Plan North West Frontier Province, since 2010 Khyber Pakhtunkhwa National Health Policy
DOT S DTC
Directly Observed Treatment Shortcourse District TB Coordinator
NPO
National Programme Officer
NTP
EDO H FANA
Executive District Officer Health
PC-1
National Tuberculosis Control Programme Planning Commission Form 1
PHC
Primary Health Care
FATA FGD GB GoP
Federally Administered Northern Area Federally Administered Tribal Area, Focus Group Discussion Gilgit - Baltistan Government of Pakistan
PPM PPP PRL PTP-C
HBC
High Burden Country
PTP
HH HIV HMIS
Households Human Immunodeficiency Virus Health Management Information System Health System Strengthening and Policy Unit Health System Strengthening Islamabad Capital Territory Information, Education and Communication Incidence Rate Ratio Institute of Public Health Japanese Int. Cooperation Agency Joint Program Review Mission
RHC TC TB
Public-Private Mix Private Public Partnership Provincial Reference Laboratory Provincial TB Programme Coordinator Provincial Tuberculosis Control Programme Rural Health Centre Treatment Centre Tuberculosis
TPE
Third Party Evaluation
TRF TSR USAID
Technical Resource Facility Treatment Success Rate Unites States Agency for International Development World Health Organisation X-Ray
BCC BHU CBO CDR CIDA CFR CT DG DDH O DFID
HSSP U HSS ICT IEC IRR IPH JICA JPRM
WHO X-R
1
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
EXECUTIVE SUMMARY The National Tuberculosis Programme (NTP) in Pakistan has gained new vigour and momentum since tuberculosis was declared a national emergency by the Ministry of Health (MoH) in 2000. Over the last decade, the NTP has been regularly assessed by the Joint Annual Review (WHO-NTP)1, but has never been subject to a third party evaluation.
Commencing in September 2010, by request of the
Government of Pakistan (GoP) and donors, a Third Party Evaluation (TPE) was undertaken by a team of seven independent consultants (three international and four local) with specific expertise, in order to provide an independent evaluation of the NTP. The team was requested in particular to review the following aspects, or ‗pillars‘, of the programme: financial management; procurement and supply chain management; human resources; laboratory and diagnostics; service delivery; operational research; and advocacy, communication and social mobilisation. The evaluation was funded by DFiD and took place over a period of eight months to June 2011, in five phases: Phase 1, Inception, included review of literature and materials, consultation with the NTP and development of the work plan; Phase 2, Methodology, that is, development of tools, questionnaires and methodology, including sampling and analysis and a stakeholder consensus workshop on evaluation framework & methods; Phase 3, Data Collection, comprised data collection at federal, provincial and district levels; Phase 4, Data Analysis; Phase 5, Writing a Report and First Draft which will be presented and revised after a consultation workshop and dissemination seminars.
Pakistan‘s fragile security situation restricted access for international consultants to much of the country. The consultants were able to collect data at provincial and federal levels, and from a local independent company, Right & Health-Alliance for Integrated Development (RH-AID), which was contracted to implement data collection at field level. Methodology, tools and questionnaires were developed by the consultant team and RH-AID with stakeholder consensus, and data collection took place during March and April 2011. The entire exercise was subject to a series of constraints, including limited access to certain districts due to floods in 2010, deplorable weather conditions particularly in winter and the unstable security situation in three of the eight administrative units of the country. 1
The joint WHO and partners evaluation is an independent evaluation. Several partners are engaged: Union, GFATM, KNCV, USAID and MSH
2
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Due to the large quantity of data and information involved in this study, the TPE is presented in three volumes; Volume 1 presents findings, conclusions and recommendations of the TPE, Volume 2 contains methodology and annexes, and Volume 3 contains the analysis of data collected in the field by RH-AID. Prior to this TPE, it was clear from the available epidemiological data (2000 - 2010) that the NTP is a success story in the Pakistani health panorama and has achieved good results in the containment and reduction of the disease in the country. NTP‟s Main Results2 in the Last Decade 2000-2010 NTP is a success-story in the Pakistani health panorama. Regular achievements and improvements have marked the programme, especially during the last decade, thanks to the government political commitment, a well tuned and dedicated team at all levels (NTP, PTP and districts) and the constant financial and technical support of main stakeholders and partners. The goal of the Stop TB Strategy, that is, to reduce the global burden of TB in line with the Millennium Development Goals and the Stop TB Partnership targets, has been achieved, alongside partial achievement of the specific objectives of the programme which are to: achieve access to quality diagnosis and patient-centred treatment; reduce the human suffering and socioeconomic burden associated with TB; protect vulnerable populations from TB, TB/HIV and drug-resistant TB; support development of new tools and enable their timely and effective use; protect and promote human rights in TB prevention, care and control; reduce the incidence, prevalence and death rates associated with TB; and increase the proportion of TB cases detected and cured under DOTS. Over the past decade, the NTP has achieved the following results:
A rapid expansion of the DOTS strategy from 2000 to 2005 allowed DOTS-all-over coverage in May 2005;
Free diagnostic and treatment facilities for TB patients have been available countrywide within the public sector health care delivery network, including rural health centres, Tehsil and district headquarter hospitals in addition to certain tertiary care teaching hospitals;
The proportion of Smear Sputum Positive pasted from a 39% in 2001 to a 50% in 2010;
2
For specific sectorial results please refer to each report chapters
3
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
The Case Notification Rate SS+ increased from 5 to 59/100,000 and CNR all types to 10 to 155/100,000 in 2010;
The Cure rate increased from 64% in 2003 to 74% in 2009;
The Defaulter rate dropped from 14% in 2001 to 4% in 2009;
The case numbers have increased with DOTS expansion to private sector and tertiary care hospitals. Case detection rate increased from 3% in 2000 to 17% in 2003. In 2009, it was 76% (63-93%);
The Treatment Success rate also increased from 74% in 2000 to over 90% in 2009 and to date has been maintained against the target of 85%;
Through countrywide implementation of DOTS, the programme has strengthened and supported a network of 11,445 diagnostic centres and about 5,000 treatment centres in 134 districts of Pakistan (i.e. 100% public sector coverage);
In addition, the programme also successfully initiated implementation of DOTS in more than 35 teaching and specialised hospital in four provinces, as well as, a network of about 1000 private clinics in five major cities and ten districts of the country;
According to the WHO Global Report 20093, the programme almost achieved the 70 - 85% target: CDR for 2009: 76% (63-93%) and TSR for 2009: 91%. The private sector managed more than 19% of the TB cases registered in 2010.
Nevertheless the TPE revealed that while the overall operation has been successful, there exist several areas of key concern and ample room for improvement, especially relevant to the decentralisation process of the health programmes across the country. Findings for each of the seven ‗pillars‘ of the NTP are as below. Although it is not news, the TPE brings to attention the Financial Sustainability of the programme. NTP donor funding constitutes over 85% of total NTP funds over the past five years, with donor funding exhibiting an increasing trend, particularly
3
As of 2009, WHO reports CDR for TB (not ss+), see p.13 box 6 in the Global TB report 2010 for the 2009 data
4
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
over the last three years. This is an issue that the GoP needs to acknowledge and address. While NTP is Financed through two different funding streams (GoP and Donors), there is no evidence of duplication in funds utilisation. GoP funds complement donor funding of ongoing activities/interventions of NTP. Funds available for the Provinical Tuberculosis Programmes (PTPs) from the provincial governments are utilised since donors contribute in kind only. Government ownership of the program at the provincial level is considerably higher than ownership at the federal level, primarily due to the longer term PTP use of the provinces‘ own resources. Donor release of funds for NTP is found to be more apt than GoP funds. Lead-time analysis of NTP and PTPs finds the fund flow mechanism to be inefficient. At the NTP level, the evaluation finds the financial management team to be competent, meeting the required experience and qualifications criteria. Issues such as understaffing and under-qualification of staff are identified at provincial level. Lack of relevant financial management training is identified as a serious weakness at both tiers of the program. Financial management capacity of the district TB Control programmes also appears to be weak. The issues of funding, sustainability and ownership reflect the Human Resources (HR) situation, showing no clear evidence of long and short-term planning and strategy. A large number of key staff, especially at federal level, and including laboratory staff, is employed using foreign funds, which will need to be replaced using the national budget gradually. There is a thin computer data base of staff details, and 84% of the TPE sampled staff did not have job descriptions available, both at national and all provincial/regional levels. There are no performance reports or appraisal systems in place which revealed accountability problems. In provinces and districts, trainings only follow the targets set by the Global Fund (GF/GFATM). There are no training plans based on any prior training needs assessments made at provincial and district levels. HR reform initiatives have started taking place at NTP, but provincial and regional programmes need to align their HR needs and reforms accordingly. The TPE found that the current Procurement and Supply Chain Management System has had a direct positive impact on the overall outcomes and achievements of the tuberculosis programme. The TB programme supply chain has also shown the capability to mitigate unplanned risks such as loss of supplies due 5
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
to flooding in 2010, and reduced provincial PC-1 funding. However, it was found that the provision of uninterrupted tuberculosis treatment is at risk, due to insufficient buffer stock at all sampled health system levels (46 % of health facilities do not keep a buffer stock), and stock-outs of Category II and Childhood TB supplies are seen at field level health facilities. Donors, who have provided technical, financial and supervisory support, have been a key factor in successful implementation of the NTP Drug Management Guidelines. Again, a high proportion of positions within NTP and PTP PSM departments are 100% donor funded, which suggests a decreased government capacity for procurement and supply management. Annual procurement plans for different donors (GFATM, GIZ, Japanese grant, KNCV, GIZ, PC-1 government funds) do not follow a strategic coordination process. There is no strategy to ensure availability of drugs when provincial and federal PC-1 funds are not forthcoming, nor is it available in case of phase-out of GFATM funding. Regarding Diagnostic and Laboratory Services, a mainly well functioning microscopy network has had a direct and positive impact on TB case notification. The National Tuberculosis Referral Laboratory (NTRL) plays an important role in HR development, the quality assurance (QA) scheme and in conducting surveys. The ongoing TB prevalence survey will help the programme determine the actual disease burden of bacteriologically confirmed TB cases, developing strategies and planning for TB control on actual disease burden. Overall, the objective to provide access to quality assured laboratory services for diagnosis of smear positive TB cases is largely met. An increase in smear positive TB notification rates from 29/100 000 population in 2005 to 60/100 000 population in 2010, coincided with an increase in the number of diagnostic microscopy centres from 982 to 1170, confirming a great expansion of the NTP laboratory network in recent years. Further improvements can be made with increased supervision of laboratory services at district level and improved coordination between laboratory and programme supervisors. However, review of NTP case notification data, available laboratory data, as well as the TPE survey indicates that National Guidelines on case finding are not always followed., Focusing on laboratories showing unacceptable performance (31% for DSM laboratories and 74% for DST laboratories under EQA in 2010) and improving Culture and DST laboratories (EQA coverage in 2010: 91% for direct smear microscopy (DSM) laboratories, 64% for culture and DST laboratories) along with enhancing the quality of smear microscopy services by adapting the external quality assurance system (EQA) to all 6
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
microscopy services is essential in order to prevent missing diagnosis of TB cases and detection of drug-resistant treatment failure cases. Currently, laboratory services for diagnosis of smear negative and MDR TB is severely limited. The TPE Service Delivery component highlights that the goals and purpose of the logical framework of the Stop TB strategy implementation plan of the ― 2005-2010 National Strategic NTP Plan‖ are in line with the WHO-STOP TB international recognised standards.
The overall package of health care initiatives is also
intrinsically linked to MDG targets 5, 6 and 8, especially in reducing incidence and prevalence of TB and HIV/AIDS. The overall package of activities provided the targeted population with a comprehensive and satisfactory quality of services. At this stage of programme implementation, most of the targets have been achieved. Nevertheless, important differences in results achievement between provinces and districts are seen, providing a non-homogenous map of success. DOTS approach is followed in the majority of the public health facilities, but there is much work to be done in relation to DOTS applications and standardisation at private level and in the para-state entities (army, railway etc). Where the monitoring and evaluation (M&E) theory and the different steps are well described and operate at federal and provincial level, the efficiency and effectiveness of those activities diminishes at the grass roots level (from districts to health facilities). Coordination with health stakeholders at regional and national (UN, Bilateral, MoH, NGOs and other institutions) level is assured by regular meetings, ensuring synergy and avoiding overlaps. However, there is a good margin to improve the provincial/district coordination along with the visibility of the programme, its achievements and their dissemination. A major component for service delivery sustainability in the future will be to strengthen and expand interaction and synergy with the private sector in all aspects of NTP operation. An Operational Research unit commenced its activities at NTP level in 2008. The priority areas identified in the operational research plan of the National Strategic Plan 2005-2010 are well aligned with the current research needs of the programme. Research studies have been conducted in a locally relevant context, focusing mainly on development of national health research systems and institutional framework for research. The proposed targets of conducting and completing at least four research studies each year have not been achieved. This aspect of the programme is solely funded by donors.
7
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Advocacy, Communication and Social Mobilisation (ACSM) approaches, strategies and activities evolved over the last decade but it was only recently, in 2008, that a comprehensive strategy and a related national monitoring evaluation framework were devised.
ACSM currently operates in less than half of the
country‘s districts. The TPE results from the field show that there is still much work to be done - while there have been plentiful activities in ACSM areas, no qualitative results are available, and the real impact of these activities is difficult to gauge. The TPE field survey results showed a striking lack of awareness not only from patients but from health staff and even though the scale of the TPE survey was small, this should nevertheless raise a red flag on current ACSM activity effectiveness. The bulk of ACSM present funding is through GFATM Round 6, which will terminate in 2012. GoP needs to revisit their approach towards this fundamental component of the NTP and consider involvement of the private sector for possible finance, and synergy with ACSM activities of other diseases/PHC. In view of the findings, the TPE provides a list of specific Recommendations for each of the analysed NTP components. There are five cross cutting issues to outline. First, the issue of the general Financial Sustainability of the programme is a major concern. In addition, the donor funding allocation is heavily dependent on the Global Fund.
The TPE recommends that the NTP should approach GoP
asking for a more consistent budget allocation and consider a mechanism for donor diversification. In view of the on-going Devolution of NTP following the 18th Amendment, management responsibilities to the provinces, the roles and responsibilities for all components of the programme need to be clearly defined, and appropriate capacity should be reinforced. Donors should also familiarise themselves with implications of the devolution to ensure uninterrupted support to the programme beyond 1st July 2011. With the NTP coordination mechanism expected to wither away by the end of June 2011, a transition strategy from funding and coordination between seven entities as opposed to just one that is, NTP, needs development with adequate implementation mechanisms. GFATM is the main source of funds for NTP. The devolution will definitely affect the central NTP coordination that plays a critical role in developing
8
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
proposals and getting the grants. The core group of human resources that coordinated the central mechanism has gained experience over the years. In case of devolution, there will be seven grants from each of the seven provinces instead of one proposal for the whole country.
Besides, the
provinces do not have enough experience in managing such complicated grants. It is therefore, recommended to maintain the central unit for TB, as done for other priority areas in the country such as vaccine preventable diseases and hepatitis. The TPE perceives the NTP to be developing into a Vertical Programme, not sufficiently integrated in the PHC approach, which remains the back bone of the Pakistan public health system. This can be viewed as a result (and shortcoming) of the financial support received in the last years from GFATM rounds. At this stage, the NTP cannot address the remaining gaps without a comprehensive health systems strengthening approach that will involve other diseases, plus synergy and collaboration with other MoH departments. The TPE highlights the Disparity of Achieved Activities amongst the different provinces, in all the NTP components. The National Strategic Plan 2010-2015 has identified this issue and has set it as a priority. Nevertheless, it is unrealistic to assume that substantial progress will be made in the less advantaged areas without an improved general security situation. The Gilgit-Baltistan, AJK, Balochistan, KPK and FATA TB Control Programmes need more focused development partners, dialogue and engagement. The Monitoring and Evaluation (M&E) system of the programme needs the urgent introduction of an internal audit function to strengthen the financial management control capacity of the programme. The urgency is underpinned by direct donor funding at the PTP level and even potentially enhanced due to the devolution through 18th Amendment. Across the various components of the NTP, monitoring and evaluation needs to be strengthened particularly at peripheral level, and to include more specific, measurable, attainable, relevant and time bound (SMART) indicators. The TPE‘s main recommendations are as follows: Finance Management (FM): The issue of delay in fund allocation and disbursement is affecting implementation efficiency and effectiveness, and thus 9
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
needs special attention (i.e. a cause analysis study). The FM capacity of the programme needs to be strengthened through specific FM training of the existing teams (including the senior management) across the NTP and PTP, and hiring of additional FM staff. For other components of the programme, the issue of differing situations within the country demand tailoring of financial solutions to the ground context. Procurement and Supply Chain Management: In relation to QA, there is a need of product standardisation and specification in accordance with the national Essential Drug list and treatment protocols. A proportion of drugs (around 50%) are procured from local companies with insufficient information about their QA mechanisms. It is recommended that WHO follows up on the prequalification of the local drug companies, by providing documentation proving their adherence to the stringent national criteria, or WHO prequalification programme, as applicable. Improvements are required in the annual forecasting process in order to ensure a minimum buffer stock level and thus, continuous supplies for treatment. At NTP and PTP, procurement processes and records should be standardised to follow the Standard Procurement Guidelines of the MoH in order to improve traceability and transparency, and fit to comply with any additional donor requirements. Human Resources: Linked to the issue of sustainability, an excessive number of NTP staff are allocated to the programme through external funding (mainly GFATM and WHO), instead of forming an integral part of the public health system. There needs to be a strong reorganization of the HR component in terms of quality and quantity. The NTP needs to develop a staffing strategy that incorporates the following: identification of roles and accountability of each staff/manager; a competency framework and job descriptions; an assessment tool for talent and skill acquisition; formal performance reviews; a range of training, mentoring and placement programmes; incentive and retention schemes, and establishment of a culture where feedback and learning are valued.
Training needs assessment
follow up is one of the weakest areas of HR component, with a need for standardised planning and monitoring. Capacity building is required for the staff across the board. A proper MIS and record keeping system need to be established as part of a comprehensive programme management system. Diagnostic and Laboratory Services: The TPE suggests that the NTP should adopt the new WHO policy of two smear examination for case findings and new 10
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
case definition of smear positive case, as per the 2010 Joint review mission recommendations ― to apply the WHO recommendations of performing two sputum smear examinations in case of quality-assured diagnosis‖. This will reduce the workload and provide opportunity for improving quality. There is room to increase case-finding by examining more TB suspects through further expansion of the laboratory service. There is a need to involve the private sector within a well defined framework (with QA scheme) and it is recommended to reinforce follow-up smear microscopy for objective and accurate evaluation of treatment response and outcomes of TB patients under treatment. For accurate and timely diagnosis and treatment of TB patients including M/XDR-TB cases, it is recommended to develop a standard protocol using efficient, affordable, conventional and advanced laboratory
techniques
(automated
liquid
culture
systems
and
molecular
techniques). Strengthening of the referral system for culture and DST, especially quick and safe transport of specimens, is essential. The National TB Reference Laboratory needs further support in terms of qualified human resources and laboratory expansion. Service Delivery: A general health system strengthening approach (HSS) is vital to allow improvement to the NTP service delivery component, including synergy to PHC and with other diseases. In addition, two main areas that will lead to improvement in the coming years are ACSM and PPM/PPP (this is well noted in the new NTP Strategic Plan 2010 – 2015). However, funding for ACSM will be minimal after completion of GFTAM Round 6. Round 9 focuses on PPP with no ACSM provision, thus there is a need to identify and formalise long term funding solutions. It is also recommended that the level of service delivery coverage found should be extended from privileged areas, such as Sindh and Punjab, to the most disadvantaged areas. Speeding up the process of switching treatment regimens from eight months to the WHO recommended six months to discourage treatment abandonment is also recommended. Looking ahead, it is advised to commence studies and trials for the four-month regimen, as adopted in other countries. There is also the need to place emphasis on DOT (direct observation of treatment) at PHCs. In rural areas, LHWs play the role of treatment supporters and although they are supervised by the LHS, the quality of DOT delivery needs to be improved. Operational Research: This component is generally weak nationwide, particularly at district level. Strengthening of the existing research unit at the national level is recommended along with expansion and skills development of the provincial teams 11
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
specifically assigned to the research and development projects. The TPE recommends shifting focus onto more practical operational outcomes of the implemented research. ACSM: As a component of the NTP that will be essential for filling the existing gaps in the coming years, it is strongly recommended that ACSM receive due attention and funding, as this is not the current situation. According to several KAP studies conducted in the region, the main source of knowledge is the media and this should be taken into consideration in tailoring future ACSM strategy by reducing the inefficient and costly ACSM activities and reorienting the funds towards more cost effective methods in order to produce a significant change in the KAPB of the community. Furthermore, the impact of the media needs to be evaluated in Pakistan. It is also advised that full geographical coverage of ACSM activities is achieved without delay. Currently ACSM is nearly solely funded by donors, and it is thus, recommended that synergy should be made with MoH for ACSM activities of other diseases. The existing ACSM M&E framework relies heavily on quantitative results. Therefore, it has been suggested that a qualitative approach, despite its complex and time consuming nature, be adopted by NTP and the GFATM PR. ACSM guidelines appear to operate mainly at federal and provincial level. Keeping in view the upcoming decentralisation process, it is essential that this information is correctly delivered and adopted at peripheral level.
12
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
1. INTRODUCTION This chapter describes the overall NTP Third Party Evaluation (TPE) report structure and the content of the three volumes. It provides a short description of the context and background where the exercise was implemented. It highlights the purpose and objectives of the evaluation and provides the management and reporting arrangements, agreed between MoH, donors, health stakeholders and implementers. The section related to the TB-TPE approach and methodology is a concise outline of what was used during the evaluation; in-depth description of those two elements is available in Volume 2. The last subdivision/component of this chapter underlines the high level of independence of this study, both in terms of the actors involved (Consultant Team) and the team involved during the field phase of data collection (RH-AID). This provides credibility and reinforces the value of the evaluation findings, results and recommendations.
1.1
Report Structure
The Third Party Evaluation of the National Tuberculosis Programme in Pakistan is submitted in three volumes: Volume 1 (this volume) is the main report, containing the main findings, conclusions and recommendations. Volume 2 contains the annexes for Volume 1, process steps and field research that specifically support Volume 1. It presents the tools and questionnaires which were specifically designed, at different levels:
The Evaluation Scope
The Evaluation Approach and Methodology
The Federal and Provincial assessment of the main five pillars
The Field Assessment at the different health/stakeholder levels
The Annexes contain the survey design, utilised tools and questionnaires
Volume 3 contains the survey results from the interviews conducted in the field in seven (7) provinces and in seventeen districts (17):
162 Health Facilities – Q1;
412 Client/Patients – Q2;
1936 Households – Q3;
239 Actual plan /124 Defaulters found Q4; 13
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
160 Interviews conducted with staff in charge of the health facility Q-5;
16 Interviews conducted with District Coordinators Q-6;
15 Interviews conducted with Executive District Officer Health Q-7;
16 Interviews conducted with Medical Superintendent of District Hospital Q8;
16 Focus Group Discussions conducted with Lady Health Workers Q-9;
16 Focus Group Discussions with community members Q-10.
1.2
Context
As of 2009 (Global TB report 2010), Pakistan ranks 6th amongst the countries with a highest burden of TB in the world and contributes to about 4% of the tuberculosis burden in the Eastern Mediterranean Region. According to the World Health Organisation (WHO) in 2009, the incidence of TB cases (all forms) in Pakistan was 231/100,000. TB is responsible for 5.1 percent of the total national disease burden in Pakistan, with substantial impact on socio economic status. The WHO declared TB a global emergency in 1993. Although initiatives like the piloting of Directly Observed Therapy Short-course (DOTS) strategy took place in 1996, DOTS implementation started only after revival of the National TB Control Programme (NTP) in the year 2000 and activities geared up in March, 2001, when the Government of Pakistan declared TB as a national emergency. High government commitment, coupled with technical leadership in the programme resulted in clear vision, which translated into a multi-year strategic plan (2001 – 2005) to achieve 100% DOTS coverage by year 2005. Reaching DOTS - All Over in May 2005 signified free diagnostic and treatment facilities for TB patients in all districts of the country within the public sector‘s health care delivery network. The strategic plan was revised for the period 2005 to 2010. Along with public sector funding, the NTP also received tremendous support from international and bilateral organization, NGOs, partners and donors. The major projects are supported by Global Fund grants (Round 2, 3, 6 and 9). The Global Drug Facility (GDF) supplemented ATT drugs. The overall objective of NTP is to reduce mortality, morbidity and disease transmission so that TB is no longer a public health problem. The national targets are in line with the Millennium Development Goals (MDGs): to detect 70% of 14
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
estimated cases and to treat at least 85% of detected new cases of sputum smear positive pulmonary TB, successfully. The NTP is responsible for overall TB control activities in the country including policy guidelines, technical support, coordination, monitoring and evaluation, and research, whereas the Provincial Tuberculosis Programme (PTP) is responsible for the actual care delivery process, including programme planning, training of care providers, case detection, case management, monitoring and supervision. Today, the programme provides 100% DOTS coverage across all provinces and areas through the public health sector facilities. The programme initiated alliances with tertiary care hospitals and the private sector, but this is at an early stage of development.
1.3
Background to the Evaluation
To ensure that the programme has evidence that it is delivering results, an independent assessment is crucial at this time, carried out by third party evaluators. The NTP has a well-designed in-house monitoring and information system that generates adequate data on programme performance, but the quality of this data is yet to be validated. It also does not capture household information – this is collected by others means, such as, KAP survey or qualitative studies. The Programme has not been evaluated through an independent source – programme assessments have been carried out through Joint Programme Review Missions, led by the WHO. Furthermore, there are significant political developments taking place including changes in the National Finance Commission award and increased provincial political voices, which can affect future federal financing. In order to fulfil the TPE objectives, the services of seven independent multidisciplinary consultants (four international and three national) were acquired. The Consultant Team (CT)4, with the support and guidance of TRF-Islamabad, implemented the five different TPE phases from September 2010 to June 2011. Scope, approach and methodology are fully described in Volume 2.
4 : (i) : Dr. Eric Donelli/Team Leader, (ii) Mr. Sher Shah Khan/Finance specialist, (iii) Mr. Jurgen Hulst /Supply Chain, (iv) Dr. Sang Jae Kim/Laboratory and (v) Dr. Sarwat Karam Shah / Research Associate; (vi) Dr. Ali Yawar Alam Epidemiologist and M&E Specialist, RH-Aid; (vii) Ms. Pauline Scheelbeek Epidemiologist, HLSP – Royal Tropical Institute.
15
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table 1: Third Party Evaluation Phases Phase
Period
Performed Activities (i) Review of literature and materials; (ii)
Phase 1
September 2010
Inception
Consultation
with
the
NTP;
(iii)
Development of the work plan. (i) Development of tools, questionnaires,
Phase 2
October-November
Methodology
2010
methodology, including sampling and analysis; (ii) Stakeholder and consensus workshop on evaluation framework & methods.
Phase 3 Data Collection Phase 4 Data Analysis
February-March 2011
April – May 2011
(i) Data collection at federal, provincial and district levels (i) Data analysis (i) Report writing and first draft; (ii)
Phase 5 Completion
May-June 2011
Consultation workshop and presentation of draft; (iii) Revision of final draft and (iv) Dissemination Seminars
The Technical Resource Facility (TRF) was established by donors, and is funded by UK‘s Department for International Development (DFID) and Australian Aid Agency (AusAID). It is a five-year project managed by the firm HLSP, a member of Mott MacDonald Group, in partnership with John Snow Inc. (JSI) and Semiotics. The TRF is mandated to support improvements in policy, strategies and systems and helps to build the capacity of government functionaries at federal, provincial and district levels by providing strategic technical assistance. The purpose of this is to help the government achieve its goal of improving people‘s access to quality health care services, thereby improving their health, with focus on poor people and marginalised groups.
1.4
Evaluation Purpose and Objectives
The purpose of this TPE is to systematically evaluate progress made by the National TB Control Programme towards national objectives and targets and in achieving the Millennium Development Goals (MDGs). The TPE examined and analysed changes over time (2005-2010) and recommended ways to further 16
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
strengthen the program over the next five years. The main objectives of the evaluation are: 1. To provide MOH and other stakeholders with accurate, credible and usable information on the performance of the National Tuberculosis Control Programme since 2005; 2. To provide analysis and recommendations on how to further strengthen programme performance to make progress towards national goal and targets and MDGs. This includes consideration of issues central to the development of a TB Medium Term Development Plan which is aligned to the National /Regional Mid Term Expenditure Framework (MTEF);
1.5
Management and Reporting
The Third-Party Evaluation (TPE) was commissioned by the Government of Pakistan (GoP) through the Technical Resource Facility (TRF). The TRF, in close coordination with the Health Systems Strengthening and Policy Unit (HSSPU) of the MoH, identified and contracted most of the national and international consultants, including the international Team Leader who directed and oversaw the entire evaluation study. Through a transparent process of selection involving the team leader, TRF/HLSP also contracted RH-Aid, a survey firm based in Islamabad that, in collaboration with the Consultant Team (CT), designed the tools and questionnaires and undertook the field surveys. The field survey/data collection included the following field activities: (a) Household Interviews, plus interviews with client/patients, defaulters, medical superintendents of District Headquarter Hospitals, District Coordinators, Executive District Officer Health, staff in charge of the health facility; (b) Provision of a health facility instrument checklist; (c) Focus group discussions (FGD) conducted with LHWs and Community members; (d) PTP and NTP field visits; and (e) Generating questionnaires for the six pillars of the TPE namely, service delivery, laboratory, HR, procurement & logistic, ACSM and finance. DFID provided the financial support to fund the evaluation. The work of the evaluation team was overseen by an Advisory Forum who acted as a steering committee and comprised of the following members:
Secretary Ministry of Health / nominee by the secretary;
Secretary Cabinet Division / nominee by the secretary;
National Program Director NTP; 17
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Chief HSSPU;
Representatives from AusAID and DFID.
The evaluation team were supervised on technical matters by a Technical Review Panel (TRP) appointed by the TRF and comprising 3 members. The TRP helped review the study design, the first draft evaluation report and was informed of the implementation of the evaluation study. The overall management agreement for the TPE implementation followed a prepared Work Plan.
1.6
Study Approach and Methodology
This Third Party External Evaluation of the NTP was carried out by an international multi-disciplinary team from TRF/HLSP from September 2010 to June 2011 (final report in June 2011), commissioned by the Pakistan MoH, financed by DFID, managed by TRF and implemented by the CT and RH-AID team at Federal, Provincial, District and Household levels. In order to keep Volume 1 concise we have provided the complete NTP approach and methodology section in Volume 2. The following paragraphs outline the methodology used. In terms of the scope of work, the TPE was primarily a Programme Evaluation, which combined a variety of research methods to assess the following two main areas:
An assessment of the NTP and its implementation during the period 20052010 in terms of its conceptualisation, design, organisation, governance, financing, implementation and monitoring arrangements at federal, provincial, district and facility levels; and
An assessment of the progresses and impact of the NTP in the following areas/levels5: (a) Finance; (b) Procurement and Supply Chain Management; (c) Human Resources; (d) Diagnostics and Laboratory; (e) Service Delivery; (f) Operational Research and (g) Advocacy Communication and Social Mobilisation.
The TPE assessed different types of variables (qualitative and quantitative) at different levels of the system (federal, provincial, district, BHU and community), each requiring different sample sizes and sampling frames. Tables 2 and 3 describe the main components of the TPE, the methods and sample sizes that 5
These areas/components were specifically requested by the Advisory forum and donors
18
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
were used, as well as the main deliverables of the evaluation. For further information please refer to Volume 3. It is important to mention that, as per ToR, report priority was given to the findings of the data collection and data analysis implemented by RH-AID in the field, plus the questionnaire results from federal and provincial levels gathered by the CT. Due to the programme nature, implementation length and the number of implementation partners during the last decade, the CT attempted to avoid data duplication wherever possible. Reference to the variety of documentation related to the NTP (previous evaluations, reports, survey, reviews and analysis) is footnoted in this report in order to keep the report light, readable and user-friendly. The CT visited seven provinces (the international consultants visited only three due to the present security situation in the country) and conducted interviews with active participants in tuberculosis control and prevention at federal and provincial levels. Meanwhile, RH-AID conducted the field survey in health facilities at district and community levels. The CT reviewed a broad number of publications on Stop TB Partnership, and other relevant TB related documents. Data analysis covered various aspects of the NTP work, including tuberculosis epidemiology, funding, advocacy, and research and development.
19
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table 2:
TB -TPE Assessments at District, Provincial and Federal Levels
Component Programme assessment of NTP at Federal Level
Programme assessment of PTP at Provincial Level
Programme assessment of NTP at District Level
Issues Covered
Source and Methods
The NTP: (a) evolution of the programme 2000-2010 (b) programme objectives, targets and strategies; (c) inter-sectoral collaboration and partners; (d) achievements. Analysis of 7 main components: 1. Finance Management 2. Procurement and Supply Chain Management 3. Human Resources 4. Diagnostic and Laboratory Services 5. Treatment Services Delivery 6. Operational Research 7. Advocacy, Communication, Social & Mobilisation Brief analysis of : Relevance Effectiveness Efficiency Impact Sustainability Analysis of 7 main components: 1. Finance Management 2. Procurement and Supply Chain Management 3. Human Resources 4. Diagnostic and Laboratory Services 5. Treatment Services 6. Operational Research 7. Advocacy, Communication and Social & Mobilisation
National context through a literature review Review of previous survey, reports, evaluations, Results from Provincial and District Epidemiological data Assessments through 7 pillars questionnaires (Federal) Internal NTP documents & presentations Complemented by selective Interviews to key informant and main NTP partners Health Stakeholders GFATM round (3,6,8,9)
Outputs: Assessments through 7 pillars questionnaires (Provincial) Review of survey, reports, evaluations Key informants interviews PTP Cross checking of main epidemiological data Qualitative and quantitative factual information complemented by interviews and Outputs:
Ten (10) tools instruments 16 Districts analysis (6 Punjab, Implemented as outline in 3 Sindh, 2 Baluchistan, 2 Khyber table No3 Pakhtoonkhwa, 1GB, 1 AJK, 1 Islamabad)
20
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table 3:
Qualitative and Quantitative Assessment Measured at Health
Facilities, Clients/Patients, Households, Defaulters, Key Informant at Health Facilities, District Tb Coordinator, Edoh, District Coordinators, Medical Superintendent Dhq/Thq,Lhw and Fgds. Components Health Facility
Issues Covered
Sources & Methods
Infrastructures Questionnaire -1 Human Resources Sample No 162 Equipment Material Availability of TB DOTS services at Facility List in diagnostic and treatment level Volume 3 Prescribed Dosage Diagnostic and Laboratory Services Follow up Smear microscopy by Months Diagnosis of Smear – cases on treatment (year) TB Drugs Stock-out Service Delivery and Utilisation
Community Base (TB Client Interview)
Demographic & Socioeconomic Q-2 No 412 Background Health Status regarding TB Tuberculosis Knowledge TB history & understanding of health status Service delivery Treatment Related factors Communication between healthcare providers and TB patient
Households Level (HH KAP)
Demographic background Health Status TB knowledge TB attitudes
Households (Non compliant/defaulter TB patient)
Demographic & Socioeconomic Q-4 No 124 Background Health Status Regarding TB Tuberculosis Knowledge TB Attitudes and Barrier to Health Seeking Behaviour TB Information: Impact of Diagnosis, TB treatment, Stigma and Adherence.
Health Facility (Key Informant Interview – In charge)
Human Resources Staff Capacity to Perform Functions Diagnostic and Laboratory Services
and
Socioeconomic Q-3 No 1936
Q-5 No – No 160
21
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Logistic and Supply Management Treatment Services Treatment Services for Childhood TB Monitoring & Evaluation ACSM
District Level (Semi-structured Key Informant Interview – District TB Coordinator)
District Health facilty Monitoring and Supervision Monitoring of outputs and outcomes Human Resources Logistic and Supplies management Public Private Mix (PPP) Financial Management Diagnostic and Laboratory Services Operational Research ACSM
District Level (Semi structured questionnaire with EDOH)
Health Sector Management in the Q-7 – No15 District Context Health problems, service delivery, and programs Community satisfaction Resource and support system Procurement, laboratory and finance
District Level (Semi structured questionnaire with Medical Superintendent of DHQ/THQ)
Hospital management Q-8 - No 16 Health problems, service delivery and programs Coordination and collaboration Resources and support system
Community Level LHW-FGDs (Community Based Treatment Observer)
Main themes developed during FGD Q-9 – No 16 Overall Duties Knowledge Person-Skill Job Satisfaction Acceptance in the community/Stigma Documenting & communication with health facility Issue surrounding management of TB patients
Impact assessment of NTP measured at Community Level Leaders and Members-FGDs (Services User)
Main themes developed during FGD Q-10 - No 16 Cultural perceptions about TB, healing treatment & barriers to TB treatment seeking Accessibility and coverage of TB services Community participation in health facility management Question and answers about health
Q-6 – No 16
22
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
education material
1.7
Independence and Quality
The evaluation team operated independently from the NTP. The Coordinating Board approved the evaluation ToR, drafted by the different stakeholders. The TRF, in cooperation with MoH and other relevant stakeholders, managed the bidding, selection and briefing process, and provided guidance to the evaluation team (including feedback on the final draft evaluation report submitted at the end of the evaluation process). The full text of the evaluation report will be disclosed on the TRF website (http://www.trf.org). The evaluation ToR articulated two purposes of the evaluation in very broad terms — assessing the impact of the NTP and recommending how to improve its effectiveness and efficiency — while presenting an ambitious set of questions to be answered. The ToR did not provide an evaluation framework, but specifically relied on the evaluation team to devise appropriate assessment tools, questionnaires and methodology. The aim of the report style is to be user friendly, direct and simple. Special attention has been given to provide practical/feasible recommendations that can be implemented. The evaluation team operated within a set of limitations and constraints, illustrated in the following table:
23
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table 4: Constraints and Limitation of the TPE Limitation
Explanations
Country Size
Pakistan is a big country; transport and connections among provinces and in between districts is sometimes not easy, especially in the north and in turbulent regions.
Population
Almost 200 million inhabitants are spread over a vast territory. 48,000 people died of TB in 2010 3,000 were killed in the 2010 flood – 20,000 TB patients were displaced
Climate
Phase 3 of the TPE – Data Collection – was performed during the winter. This provided additional constraints for the team involved in the field survey. Some flights were cancelled or overbooked, preventing teams from reaching scheduled destinations. Landslides and other blockages disrupted roads.
Flood
During the month of August 2010 most of the country was affected by a major flood which killed more than 3,000 people. Around 46,000 TB patients, including 20,000 infectious TB patients who could spread the disease to others – if not treated – were estimated to have been affected by the floods. Damage to infrastructure; loss of TB drugs, laboratory chemicals, reagent and microscopes, reporting and recording tools; and loss of follow-up TB cases on treatment were some of the setbacks suffered by the program, especially in Punjab. Some areas of Sindh – even at the time of data collection – were unreachable and health facilities were destroyed and unavailable. Those areas were not included in the sample size.
Security
International consultants were not allowed to reach most provinces. Only NTP- Islamabad, Punjab and Sindh – PTP were visited.
Budget
The budget limitation affected the ideal number of selected districts and HH for the field survey (in representativeness), as well as the number of HR available.
Time frame
Of course, for this type of study, there is ― never enough‖ time.
Uniformity of Interviews and especially FGDs are subject to the different style, qualitative data capacity and skills of the interviewers. Regardless of the high quality of the field team leader, this issue has to be kept in mind. TB-registers data collection
Researchers of the field teams were not trained on TB-register data collection. Some were more accustomed than others to the process of NTP TB data registry in the official register forms.
International Consultants
It was not an easy task to manage the schedules of the multidisciplinary international consultants during the different 24
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
phases of the exercise. The four live and work in four different countries and of course, due to the length of the TPE, had additional commitments. Due to programme postponements, some of them could not attend and participate to some of the scheduled phases. Communication More than ten people were involved in the TPE process (CT plus RH-AID), plus all the health stakeholders who provided invaluable contribution. In some instances, in/out communication was over burdened and misunderstandings arose i.e. weak communication and information flow from NTP to the provinces, and districts on TPE implementation. There was a delay in sending the TPE presentation letter (KPK was not aware of the TPE). Epidemiology
Availability data
Other entities
The representatives of sample size may have decreased because of the mandatory inclusion of at least one district per province – without the possibility of increasing the simple size (budget constraints) of The procedure for collecting information was tedious and there was a lack of transparency in some issues, especially for collecting and availability of finance data. There was poor data availability on TB-registers, as well as of the overall HIS.
TB The study makes consideration of other TB entities, but acknowledges the limitation of time, budget, and human resources for in-depth assessment of: MDR-TB, TB REACH Initiatives, TB-HIV, Parastatal Sector and Private Partnership Mix Other studies have documented these aspects (i.e. GFATM reports, PR and SR GF reports and M&E reports of specific missions).
25
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
2. BACKGROUND OF THE NTP This chapter provides a brief overview of the National Tuberculosis Control Programme. It begins by describing its evolution and main significant steps since the programme was revitalised in the late 90‘s. The second section presents the programme strategies, objectives and targets. It unfolds the main internal and external collaboration with health stakeholders. The penultimate part of the chapter is dedicated to a summary of its monitoring and supervision system, and it ends with an overview of the present epidemiological situation at national and subnational levels.6 The aim of this chapter is to present these major topics to people that are not directly involved in the NTP and thus, unfamiliar to the programme insights. It does not intend to provide an in-depth analysis of those programme components. Footnotes in this chapter refer to other available documents addressing that purpose.
2.1
Evolution of the Programme
There is no doubt that NTP is a success-story in the Pakistani health panorama. Regular achievements and improvements have marked the programme, especially during the last decade, thanks to the government‘s political commitment, a well tuned and dedicated team at all levels (NTP, PTP and districts) and the constant financial and technical support of main stakeholders and partners. The WHO declared TB a global emergency in 1993; since then, efforts have been made to expand partnerships and bring all stakeholders on board in order to control this disease more effectively. In 1995, the GoP endorsed DOTS strategy. However, due to abolition of the Federal Directorate for Tuberculosis Control in 1996, the program was dormant. Progress during the first three years (1995 – 1998) remained slow, because of its vertical approach, lack of consensus between federal and provincial units, and nonavailability of funds from the regular health budget. In 1998 the roles and relationship between the federal and provincial tuberculosis control program were redefined and agreed upon. However, the program was unable to achieve its goal of reducing morbidity and mortality due to TB until 2001, due to the following reasons: (a) TB was given low priority; (b) there was an undue reliance on 6 This section is a summary extrapolated from the last ― Joint Review of TB care in Pakistan‖. The Review was implemented from the 6th to the 10th of December 2010.
26
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
specialised TB care facilities, not accessible for most of the patients; (c) inappropriate diagnostic procedures and over reliance on X-ray; (d) use of inadequate and inappropriate treatment regimens; (e) poor compliance; (f) lack of recording and reporting system for evaluating treatment outcomes of TB patients; and (g) failure to ensure accessible diagnosis and treatment services, including directly observed therapy. The Health Policy of Pakistan, formulated in 2001, makes direct reference to controlling the disease in Pakistan using DOTS. The MoH declared tuberculosis a national emergency on 24 March, 2001. Under the umbrella of the NTP, national guidelines were developed and the first pilot projects started. Since then the NTP has been responsible for overall TB control activities in the country i.e. policy guidelines, technical support, coordination, monitoring and evaluation and research. Meanwhile the PTPs are in charge of the actual service delivery process including programme planning, training of care providers, case detection, case management, monitoring and supervision. The NTP consists of a well functioning central unit, with TB coordinators placed at provincial and district levels. TB services have been integrated into the primary health care system and are delivered by chest clinics in tertiary hospitals, district hospitals and BHUs. These efforts translated into a multi-year strategic plan (2001-2005) aiming to achieve 100% DOTS coverage by the year 2005. The strategic plan was revised for the period 2005-2010 and now for the period 2010-2015. With this, steady progress has been made to improve case detection and treatment success rate by placing emphasis on quality assurance of smear microscopy, drug management, community mobilization, involvement of tertiary care hospitals, NGOs and intersectoral organisations and above all, involving private sector for service delivery. Advocacy, community and social mobilisation are also mandates of the program. A rapid expansion of the DOTS strategy from 2000 to 2005 allowed DOTS-all-over coverage in May, 2005. Since then, free diagnostic and treatment facilities for TB patients have been available countrywide within the public sector health care delivery network, including rural health centres, Tehsil and district headquarter hospitals in addition to certain tertiary care teaching hospitals. The NTP has undertaken many new initiatives including a nation wide formative research for identifying risky behaviour, development of a BCC strategy, initiation of mass media campaigns, awareness seminars at a provincial level, and advocacy 27
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
activities at the district level (ACSM). Operational research takes place, though more should be done, and steps are taken to enhance the research capacity at national, provincial and district levels to design and conduct research. The NTP has completed and published several research projects. A number of research projects are in progress (please refer to chapter 7). The following tables highlight some of the main indicator trends from 2001/2005 to 2010. They are selfexplanatory. In 2001, 20,707 TB cases were registered, compared to 267,451 in 2009. Chart No 1: Absolute Number of Tuberculosis Notified Cases 2004-2010-Q3
The proportion of Smear Sputum Positive pasted from a 39%, in 2001, to a 50%, in 2010. Chart No 2: Proportion of Smear Sputum Positive (SS+) From 2001 to 2010Q3
28
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
The Case Notification Rate SS+ from 5 to 59/100,000 and CNR, all types, from 10 to 155/100,000, in 2010 Chart No 3: Case Notification Rate Pakistan/100,000
The cure rate increased from 64% in 2003 to 74% in 2009
Chart No 4: Cure Rate
The Defaulter Rate dropped from 14% in 2001 to 4% in 2009 29
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Chart No 5: Defaulter Rate Trend from 2001 to Third Quarter of 2009
The cases have increased with DOTS expansion to private sector and tertiary care hospital. Case detection rate increased from 3% in 2000 to 17% in 2003. In 2009, this was 76% (63-93%) Chart No 6: Case Detection Rate and CDR TOT) from 2001 to 2010 Q3
The treatment success rate has also increased from 74%, in 2000, to over 90%. in 2009, and to date has been maintained against the target of 85%.
30
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Chart No 7: Treatment Success Rate from 2001 to 2009-Q3
Through countrywide implementation of DOTS, the programme has strengthened and supported a network of 11,445 diagnostic centres and about 5,000 treatment centres in 134 districts of Pakistan (i.e. 100% public sector coverage). In addition, the programme has also successfully initiated implementation of DOTS in more than 35 teaching and specialised hospital in four provinces, as well as a network of about 1000 private clinics in five major cities and ten districts of the country. According to the WHO Global Report 20097, the programme has almost achieved the 70/85% target: CDR for 2009: 76% (63-93%) and TSR for 2009: 91%. The private sector managed more than 19% of the TB cases registered in 2010.
2.2
Program Objectives, Targets and Strategies
Global Targets for reducing the burden of disease attributed to TB are summarised in Table X. Achieving the targets set for 2015 is the main focus of national and international efforts in TB control. These targets aim to: (i) halt and reverse the incidence of TB by 2015 (MDG Target 6.c); and (ii) halve TB prevalence and death rates by 2015, as compared to their levels in 1990.
7
As of 2009, WHO reports CDR for TB (not ss+), see p.13 box 6 in the Global TB report 2010 for the 2009 data
31
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table No 5: Goals, Targets and Indicators for TB Control Health In The Millennium Development Goals Set For 2015 Goal 6: Combat HIV/AIDS, Malaria and other Diseases Target 6.c: Halt and begin to reverse the incidence of malaria and other major diseases Indicator 6.9: Incidence, prevalence and death rates associated with TB Indicator 6.10: Proportion of TB cases detected and cured under DOTS
Stop TB Partnership Targets Set for 2015 and 2050 By 2015: The global burden of TB (per capita prevalence and death rates) will be reduced by 50% relative to 1990 levels. By 2050: The global incidence of active TB will be less than 1 case per million populations per year.
The Stop TB Strategy8 is the approach recommended by WHO to reduce the burden of TB in line with global targets set for 2015. The strategy is summarised in Table X. The six major components are: (i) pursue high-quality DOTS expansion and enhancement; (ii) address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations; (iii) contribute to health system by strengthening the primary health care; (iv) engage all care providers; (v) empower people with TB, and communities through partnership; and (vi) enable and promote research. The Stop TB Partnership‘s Global Plan to Stop TB, 2006–2015 sets out the scale at which the interventions included in the Stop TB Strategy need to be implemented to achieve the 2015 targets.9
8
The Stop TB Strategy: building on and enhancing DOTS to meet the TB related Millennium Development Goals. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.368). 9 The Global Plan to Stop TB, 2006–2015: actions for life towards a world free of tuberculosis. Geneva, World Health Organization, 2006 (WHO/ HTM/STB/2006.35).
32
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table No 6: The Stop TB Strategy at a Glance Vision
A TB-free world
Goal
To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targets
Objectives
Targets
Components
Achieve universal access to quality diagnosis and patientcentred treatment Reduce the human suffering and socioeconomic burden associated with TB Protect vulnerable populations from TB, TB/HIV and drugresistant TB Support development of new tools and enable their timely and effective use Protect and promote human rights in TB prevention, care and control MDG 6, Target 6.c: Halt and begin to reverse the incidence of TB by 2015 Targets linked to the MDGs and endorsed by Stop TB Partnership: - 2015: reduce prevalence of and deaths due to TB by 50% - 2050: eliminate TB as a public health problem 1. Pursue high-quality DOTS expansion and enhancement 2. Address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations 3. Contribute to health system strengthening based on primary health care 4. Engage all care providers 5. Empower people with TB, and communities through partnership 6. 6. Enable and promote research
The three NTP Strategic Plans (2000-2005, 2005-10, 2010-2015) have been developed according to these global targets, and reshaped according to the level of implementation and achievement of the programmes‘ different components i.e. case detection, diagnosis, treatment, laboratory, logistic etc.
Nevertheless, the
overarching main priority of the tuberculosis control programme has always been the treatment and cure of tuberculosis patients, especially of patients whose sputum is positive on direct microscopy.10
10
Sputum smear-positive patients are the most potent sources of infection and, without chemotherapy, have poor outcomes, as two-thirds of them die within 2-3 years. Smear-negative patients must also be given chemotherapy if the presence of active Tuberculosis is ascertained.
33
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
The Mission of The Current NTP Strategic Plan 2010-15 is to achieve countrywide control of TB through effective implementation of the National Stop TB strategy. This includes quality assured TB care through public and private health systems, and enhanced role of civil society partners as well as communities in the nationwide TB control effort. The overall purpose of this plan is to help the underperforming four provinces, the AJK, GB and KPK in controlling TB by establishing and operating effective delivery and management of public and private TB care and support for their respective populations. In light of the achievements made so far, and the priority challenges to be addressed in the coming years, the NTP plan‘s Main Objectives are to: (1) Sustain and Consolidate the Following Targets: (a) 100% public sector DOTS coverage in the country; (b) detect at least 70% of the estimated incident TB cases; (c) treat successfully, at least 85% of the registered new smear-positive TB patients; and (2) Achieve the Following Targets by 2015: (a) enhance the capacity of the public and private sectors to detect11 80% of the estimated MDR-TB incident case and put them on treatment; (b) reduce, by 50%, the prevalence and the mortality due to TB (in relation to 1990) and (c) make progress towards eliminating TB from Pakistan by 2050. Revision of the last National Strategic Plan 2010-2015 enabled the programme to review the Global Stop TB Strategy, and accordingly, plan the implementation of the six key elements of the strategy in Pakistan. This new NSP places emphasis focusing on PPP/PPM, MDT-TB, ACSM, HSS, civil society and community.
2.3
Inter-Sectoral Collaboration and Partners
Pakistan‘s TB control efforts are supported by numerous multilateral and bilateral donors as well as associations, private foundations and NGOs (international and local). Some are long lasting partners who continue their support; others are no longer involved in TB activities, yet, they supported the programme in the life span of this TB-TPE (2000-2010). Others have only recently joined the TB challenge as sub- recipients of different GFATM rounds and/or are partners in ongoing implemented activities. The table below provides a brief overview of these partners (their respective web-site contact is listed for more in-depth information).
11
The global plan is to test at least 20% of new and 100% of previously treated cases, and put 100% of detected M/XDR
34
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Table No 7: NTP Partnership and Support in Pakistan Partner
Description of Support and Partnership World Health Organization (WHO) - http://www.who.int WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. WHO supports to enhance quality DOTS: After achievement of DOTS ALL OVER in Pakistan, WHO continues to assist MoH in collaboration with other partners (USAIDS, CIDA, DFID, GFATM and other national partners) to achieve the global targets, i.e. 85% treatment success rate and 70% case detection rate (CDR). Monitoring and supervision, surveillance system and capacity building at province and district level was done mainly through WHO/USAID umbrella grant for TB control programme, and CIDA supported lady health workers (LHWs) involvement to DOTS services and expansion of the external quality assurance (EQA) to strengthen lab network. One international medical officer is recruited at federal level and national staff at federal and provincial levels. At present WHO is assisting NTP in enhancing partnerships for TB control and involved of tertiary care hospitals and enhancement of PPM activities results in prominent increase of case notification through increasing the access to DOTS services of the people. Global Drug Facility (GDF) - http://www.stoptb.org/gdf The Global Drug Facility (GDF) for tuberculosis launched on World TB Day 2001. It has supported TB courses to supplement the public sources of anti-TB drugs, for rapid expansion of DOTS during the last years. It had also provided paediatric anti-TB drugs. United States Agency for International Development (USAID) http://www.usaid.gov USAID supports to supplements supervision/ monitoring arrangements in provinces, supplement the core training of public sector trainers in provinces, and enhance capacity for managing drugs and coordinating operational research through WHO. USAID is supporting a 12-month TB prevalence survey to determine the burden of TB and improve the planning and delivery of TB services in the country. The project ― Strengthening of Tuberculosis response to Enhance the Quality of DOTS Program in Pakistan‖ in collaboration with WHO (2004-2009) supported the National TB Control Program (NTP). It strengthens coordination and supervision at the provincial and district levels, improving laboratory capacity, conducting advocacy, communication and social mobilization activities and establishing referral links between public and private sectors. The project has helped Pakistan achieve the MDG for TB. Global Fund to Fight Against AIDS, Tuberculosis and Malaria (GFATM) http://www.theglobalfund.org/en/ GFATM Round 2-3- 6 -8 and 9
35
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
KNCV Tuberculosis Foundation - http://www.kncvtbc.nl KNCV Tuberculosis Foundation is an internationally acclaimed centre of expertise for TB control, founded in 1903 that played a major role in the sharp decline of TB in the Netherlands last century. KNCV Tuberculosis Foundation officially opened its office in Pakistan in July 2009. KNCV is the lead coordinating partner for The Tuberculosis Control Assistance Program (TB CAP), a USAID cooperative agreement (2005-2010) that was awarded to TBCTA. The Tuberculosis Coalition for Technical Assistance (TBCTA) is a partnership between major international organizations working on TB Control. The collaborating partners in Pakistan are (a) World Health Organization (WHO) ; (b) International Union Against Tuberculosis and Lung Disease (The Union) (c) Japan AntiTuberculosis Association (JATA) and (d) Management Sciences for Health (MSH). KNCV is now involved in the ongoing prevalence survey. Gesellschaft für Technische Zusammenarbeit (GTZ) (German Technical Cooperation) http://www.gtz.de/en/ (recently renamed GIZ) The German government supports programmes in the NWFP through GTZ and KFW to provide technical and financial assistance including equipment, drugs and laboratory supplies for the provincial PTP. Specific TB cooperation covers: (1) Capacity building of health managers and personnel to improve management and technical skills; (2) Advocacy for TB related health issues and (3) Tangible improvements in the quality of services, tuberculosis control measures for example Kreditanstalt für Wiederaufbau Bankengruppe (KfW) http://www.kfw.de The German Financial Cooperation has agreed with Pakistan that support for the health sector will be provided to the country in the following three core areas: Setting up healthcare structures at district and local community level (basic health), Reproductive health, and fighting tuberculosis. TB PPM in KPK. Department for International Development (DFID) http://www.dfid.gov.uk DFID has provided supported to the recovery of the TB control in earthquake-affected districts of AJK. ACSM activities and renovation of reference laboratory. It is the sponsor of the TB-TPE. International Union Against TB and Lungs Disease (IUATLD) http://www.theunion.org The International Union Against Tuberculosis was founded in October 1920 in Paris by 31 national lung associations that saw the need for a central agency to support their efforts to stop TB by organising conferences, offering training, producing publications and disseminating the latest research and information on the disease. These are core activities of The Union. In 2009, The Union redefined its vision: to bring innovation, expertise, solutions and support to address health challenges in low and middle income populations. These goals reflect the interrelatedness of TB and lung disease with other conditions ranging from HIV/AIDS to diabetes and the fact that the burden of disease falls most heavily on the poor.
36
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Canadian International Development Agency (CIDA) http://www.acdi-cida.gc.ca From 2003-2009, CIDA supported The Union to embark on a ground-breaking initiative entitled "Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB" (FIDELIS). The grant was part of CIDA's contribution to FIDELIS. The program aimed to increase case detection of infectious cases of TB, while maintaining high cure rates within the DOTS strategy. Two of the unique and overriding principles of FIDELIS were the focus on patients with limited access to health service and the support of locally developed and innovative solutions to case detection. Between 2003 and 2008, a total of 51 phase I projects were completed in over 15 countries including Pakistan. CIDA also supported various GFATM rounds as well as the LHW program. CIDA represents part of Canada's contribution to the Global Drug Facility (GDF), a program of the Stop TB Partnership. It provides access to anti-TB drugs for governments that agree to introduce, expand, or maintain the diagnostic, treatment, and monitoring policies of the DOTS strategy. Canada was the founding donor of the GDF and to date (2010) has been the single largest donor country for first-line TB drugs. Australian Agency for International Development (auAID) http://www.ausaid.gov.au Australian assistance to Pakistan is growing as part of a substantially increased Australian engagement with Pakistan. Significant investments in health will strengthen national systems for improved service delivery, including through a major national program in maternal and newborn child health, which is being delivered in partnership with the Government of Pakistan and the UK's DFID. Australian assistance to Pakistan focuses on health (particularly maternal and child health) and basic education, aligning with key Millennium Development Goals (MDG) 4 (child mortality), MDG 5 (maternal health) and MDG 2 (universal education). Japan Internationl Cooperation Agency (JICA) http://www.jica.go.jp/pakistan/english JICA provide a long term support to NTP including to strengthen DOTS implementation in four selected of Punjab through core training of staff, supplement material inputs and technical support. Association of Social Development (ASD) http://www.worldofasd.net Association for Social Development is a non-government health systems research and development organization based in Islamabad under the acronym ASD. Established in 1995, ASD works in partnership with the national institutions and disease control programmes as well as international teaching and research institutions and development partners. It has been a technical partner of the National TB Control Programme in designing and carrying out a series of research and development activities to make effective the planning and implementation of DOTS strategy package in Pakistan. The main source of support for the research activities has been DFID, through its TB knowledge programme.
37
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
The Basic Development Needs (BDN) initiative was first launched in Pakistan during 1995 in the Nowshehra district through WHO support, and replicated in six districts from all the four provinces and regions to galvanize the holistic vision of primary health care (PHC). The GFATM substantiated the contribution of the BDN communities towards TB and Malaria Control through three successive grants during Round-3 (Malaria and TB components), Round-6 (TB Component) and Round-7 (Malaria component). A total of 3,826 LHWs and 1,476 female volunteers were trained. Community awareness on TB / Malaria was raised through more than 6,500 health promotion events were organized focusing on Malaria and TB control. Around 25,000 volunteers including CRs, LHWs, and CHV were trained on the preventive strategies of Malaria and Tuberculosis, while more than 13,000 LHWs and CRs were trained in community mobilization techniques and direct observation of treatment to TB patients. 2,500 health care providers were trained in Malaria and TB case management, diagnostic facilities for Malaria and TB were strengthened in 69 diagnostic centres, and 581 laboratory technicians were trained in TB microscopy. The case detection rate of Tuberculosis patients thus rose from 45% to 80%, the treatment success rates from 61% to 91%, with a reduction in the default rate from 12% to 3%. Association for Community Development (ACD) is a Peshawar based NGO registered in Pakistan. The aim of the society is ― to improve preventive, promote, curative and rehabilitative health services for the local and refugee population in Pakistan‖. The Association provides technical inputs to the National and Provincial TB control programme, WHO Pakistan, WHO and MOH Afghanistan, UNHCR and national and international NGOs. ACD has been implementing Tuberculosis control programme for Afghan refugees, through 146 basic health clinics, including 48 field laboratories and a central reference laboratory in the entire province of NWFP in partnership with the government as well as national and international NGOs. ACD has been actively involved in developing training and health education materials in local language, and training the program managers, doctors, paramedics and laboratory technicians, community health workers and community volunteers in TB control and DOTS implementation. ACD has also been involved in studying the primary and acquired drug resistance as well as typing the strains of mycobacterium TB in the Pakistani and Afghan TB patients. GreenStar Social Marketing - http://www.greenstar.org.pk Greenstar Social Marketing Pakistan (Guarantee) Limited (originally called ― Social Marketing Pakistan‖) was established by Population Services International (PSI) in 1991 as a non-profit devoted to improving quality of life among low-income people. A nongovernmental organization, Greenstar works through the private sector and with the Government of Pakistan, empowering healthier choices and to motivate and create demand among low-income Pakistani women and men for health services and products. This is achieved through mass media campaigns on television, radio, newspapers, billboards, public relations, Clinic Sahoolats (Free Clinics), mohalla (neighborhood) meetings, and seminars. In partnership with National TB Control Program (NTP), Ministry of 38
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Health, Greenstar (GS) is implementing one of the Global Fund Round 3, 6 and 9 supported projects on TB. The objective of this program is to create greater knowledge and provide increased access to high quality TB DOTS information, testing and treatment through a private sector clinic franchise - GoodLife Stop TB Network, in 5 major cities; Karachi, Lahore, Rawalpindi, Peshawar and Quetta. The Greenstar public-private-partnership strategy appears to serve as a model in Pakistan to engage providers to deliver quality TB services accessible to vulnerable, low-income population. Infectious Diseases Society of Pakistan (IDSP) http://www.idspak.org Karachi Infectious Diseases Society formed in 1993 with the aim to assimilate and disperse knowledge in this field. Bridge - http://www.bridgeresearch.org.pk Bridge is a not for profit organization registered as a trust, under Trust Act 1860 with Government of Pakistan. The main objective is to promote research, training, innovative public health interventions and advocacy for better health, education and social development of impoverished communities in the country. Head office is centrally located in PECHS Karachi, and branch offices are in all major cities of Pakistan with full time administrative, accounting and computer services support staff. There are field project offices in all major cities throughout the country. Marie Adelaide Leprosy Centre (MALC) http://www.malc.org.pk MALC is also supporting National TB Control Programme and providing the following services through its leprosy centres in the entire country. (a) DOTS supervision in remote and difficult to reach areas; (b) Defaulter tracing and analysis of defaulting; (c) Contact screening for early case finding and stopping the transmission; (d) Proper follow up of TB patients; (e) Supervised therapy for prevention of MDR (Drug Resistant TB); (f) Social help to needy patients (Nutritional support) (g) Health Education to patients and their families – at community level. It functions in all Provinces and attends to over 9,000 TB patients annually. MALC has established Diagnostic and Treatment facilities all over Pakistan. A total of 140,447 patients have been registered since its launch. Cure completion rate has been achieved above 90%. Treatment Success rate has been achieved 94% and Sputum Positivity rate +/- 50% has been achieved almost in all project areas. MDR patients are also seen occasionally and treated through networking. Pakistan Paediatric Association (PPA) - http://www.ppa.org.pk The Pakistan Paediatric Association (PPA) members are qualified paediatricians. There are five branches, which cover geographic regions in the country. Mercy Corps (MC) - http://www.mercycorps.org Mercy Corps (NGO) is the principal recipient of TB GFATM Round 6 and 9. By partnering with a range of partners, from village health committees to government agencies, Mercy Corps helps build the means to improve maternal, newborn and child health, ensure proper nutrition and combat infectious diseases
39
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Pakistan Anti TB Association (PATA) - http://www.patba.org Pakistan Anti TB Association (PATA) is a community based non profit, non government and single object organization working exclusively for treatment, rehabilitation and welfare of TB patients throughout the country, having national & international references and is a member of IUATLD-SEAR. There is a country wide network of more than 100 Diagnostic centres (Basic TB Management Units) for TB services with more than 200 associated Treatment centres. During GFATM Round-2 project Pakistan Anti TB Association succeeded in detecting and registering 28,442 New Sputum Smear Positive cases and put them under DOTS strategy whereas the project target was limited to 22,000 NSS+ cases and achieved the treatment success rate of above 90% against 85% desired by WHO. The Asia Foundation (TAF) - http://asiafoundation.org The Asia Foundation is a non-profit, non-governmental organization committed to the development of a peaceful, prosperous, just, and open Asia-Pacific region. In Pakistan they conduct a baseline survey and consultation and orientation sessions focused on the health monitoring committees created under the Sindh Local Government. Aga Khan Hospital Services Pakistan (AKHSP) http://www.aku.edu/ Aga Khan University Hospital, Karachi, (AKUH,K) started operations in 1985, as an integrated, health care delivery component of Aga Khan University (AKU). Involved in MDR-TB, research and paediatric TB. This University Hospital has 563 beds in operation and provides services to over 50,000 hospitalised patients and to over 600,000 outpatients annually with the help of professional staff and facilities that are among the best in the region. Care is available to all patients in need. Those who are unable to pay for treatment, receive assistance through a variety of subsidies and the Hospital's Patient Welfare Programme. Pakistan Chest Society (PCS) - http://pjcm.net Pakistan Journal of Chest Medicine is a peer review journal published every quarter of the year. Original articles, review article, case reports and special communication related to the field of Chest Medicine are welcome for publication. Pakistan Journal of Chest Medicine is published on controlled circulation basis and mailed to members of in hospital setting and private clinics throughout Pakistan and abroad. Integrated Health Services (IHS) - http://ihspakistan.com Integrated Health Services (IHS Pakistan) is Pakistan's leading health organization involved in health service delivery through establishing clinics, hospitals, labs and home & emergency medical response systems (covering both curative & preventive aspects) besides school, occupational & corporate health services, health research, consultancies and health infrastructure development. Operating Pakistan‘s largest school health service, corporate & occupational health system, home medical care service and health consultancy organization. This occurs with funding from GFATM Round 6.
40
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
2.4
Monitoring and Supervision System
The NTP has a strong monitoring system in place, which is analysed on quarterly and annual bases to provide national information on Case Detection Rate and treatment outcome. Regular programme reviews and visits by National Programme Officers (NPOs) take place for physical verification of the quality of services. Quarterly meetings are held at the national, provincial and district levels. At national level, quarterly inter-provincial meetings are convened for programme revision, validation of provincial surveillance reports, planning, and consultations on new issues or initiatives. The meeting is attended by all provincial managers, NPOs, and NTP partners (inclusive of those involved in PPP DOTS). At provincial level, quarterly inter-district meetings are held for revision and validation of district data and consultations on various issues. These meetings are attended by all Executive District Officer Health (EDOs-H), District Coordinators, NPOs of the respective provinces, partner organisations, and a senior technical person from NTP. At district level, quarterly intra-district meetings are conducted to discuss issues and compile and analyse district data. The EDOs-H, District Coordinators, Medical Officers, DOTS facilitators and laboratory assistants of all Diagnostic Centres attend the meeting. In districts where private partners are involved in implementation of DOTS, the meeting is also attended by GPs, who present their data and discuss issues. The NPOs of the respective districts are responsible for facilitating these meetings and disseminating their quarterly reports to the provinces and to NTP. Their reports are regularly analysed by a National Technical Officer based at NTP who provides feedback. The District Coordinators should visit the Diagnostic and Treatment Centres within their districts on a regular basis for supervision of TB DOTS activities. They are also responsible for collecting reports from these centres and compiling district reports for dissemination to the PTPs. During the last five years of GFATM support (Rounds 2, 3, 6, 8, and 9), the NTP improved and developed a more comprehensive and sophisticated M&E. The first comprehensive NTP M&E plan in 2008 was developed through a step by step, collaborative process involving the two selected principal recipients (PR), NTP and
41
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Mercy Corp, plus other stakeholders, and covered phase 1 of the grant (November 2007 – October 2009) . With the finalisation of the NTP Third Strategic Plan 2010-201512, the latest comprehensive M&E plan was updated with revisions based on the findings and feedback from the 2008 GFATM mission. The newly drafted plan is aligned to the framework of the national strategic plan and follows GFATM guidelines.
2.5
Epidemiological Situation at National and Sub-National Level (2010)
Pakistan is one of the 22 high tuberculosis burden countries in the world. In 2009, the incidence of TB cases was estimated at 420,000 cases with an estimated incidence rate of 231/100 000 for all forms. The prevalence and mortality rates were estimated at 355 and 33 per 100 000 population, respectively. In terms of progress towards the 2015 targets, the 2009 prevalence and mortality rates constituted 63% and 40% of the baseline rates in 1990 (564 and 82 per 100 000 population, respectively). Pakistan reported a case detection rate of 76 % (63%-93%) in 2009. The estimated incidence was revisited in 2009, based on expert opinion concerned about the extent of under-reporting. This was the first revision since the late eighties, when disease prevalence survey results were reported and served as the basis of current estimated incidence rates.
A disease prevalence survey and Capture TB study are currently underway to provide accurate estimates about the true disease burden and case detection rates. In spite of current uncertainties about the estimated burden, the notification rate has significantly increased during the period 2001-2009 to reach 155 and 59/100 000 for all forms and smear positive in 2009 with an average annual increase of 27% during that period, supporting an increase in case detection rate (Fig 1).
12
The first two plans covered respectively 2000-2005 and 2005 -2010
42
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Figure No 1: Case Notification Rate in Pakistan 2000 - 2009
However, the significant increase in case detection/notification that was observed during 2001-2007 has slowed down during the 2007- 2009 period, reporting an annual increase of 4% only during the latest period. PPM initiatives account for an increasing share in notifications. As in 2008, Punjab showed a significant increase in case notifications, reporting an annual trend of 8.8% during 2007-2009, followed by AKJ (annual trend of 5.6%) and KPK (annual trend of 3.9%). Other provinces showed slight or no increase (Sindh and FATA) and even a decrease (Balochistan, and NA). (Fig 2-9) Figure No 2: Cased Notification Rate per Province in 2009
43
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Figure No 3: Case Notification Rate in Punjab during 2001 – 2009
Figure No 4: Case Notification Rate in AJK during 2001 - 2009
Figure No 5: Case Notification Rate in Balochistan during 2001 - 2009
44
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Figure No 6: Case Notification Rate in Sindh during 2001 - 2009
Figure No 7: Case Notification Rate in NWFP during 2001 - 2009
Figure No 8: Case Notification Rate in FATA during 2001 - 2009
45
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
Figure No 9: Case Notification Rate in Nas during 2001 - 2009
Importantly, when the Joint Annual Review (JAR) analysed the trend at the district level, nationwide, one third of the districts showed either stagnant or even declining numbers of case notifications: 18/30 (60%) districts showed stagnation or decline in Balochistan; 5/25 (20%) in KPK, 13/36 (36%) in Punjab, 6/25(24%) in Sindh, 2/8 in AJK, 3/7 in FATA, 6/6 in NA. (Table1-2) Regarding the relative proportion of the different tuberculosis types, smear positive pulmonary TB constituted 47% of pulmonary TB cases and 38% of all cases, extra pulmonary TB 16% of cases, while re-treatment cases constituted 3% of cases in 2008 (Fig 10). Figure 10:
Distribution of Different TB Types in 2010 – Pakistan
46
Third-Party Evaluation of the National Tuberculosis Control Programme in Pakistan
With respect to gender distribution, the female to male ratio was 1.0 for smear positive cases in 2009, with female predominance in Balochistan, FATA, NAs, and KPK. The highest age-specific notification rate is in the age group ‗55 years of age and older‘ in both sexes. The population standardised average age has increased from 34 to 39 years old during the period 2001-2009 suggesting an improved epidemiological situation. The national average treatment success rate was 90% for the 2008 cohort, with low death, failure, default and transferred out rates (2%, 1%, 4% and 3%, respectively). All provinces reported a treatment success rate higher than the target of 85% except Balochistan where the treatment success rate was 82%, mainly due to a high defaulter rate of 10%. Multidrug - Resistant Tuberculosis (MDR-TB): Pakistan ranks 4th among the 27 high burden MDR-TB countries. The estimated number of MDR-TB cases in 2009 accounted for 11,961, with a prevalence of 2.8% (
