Fix health service delivery gaps to get rid of tuberculosis

Today is the World Tuberculosis (TB) day, a day designated to build public awareness that TB is an enormous public health threat. According to statistics from the World Health Organisation (WHO), one-third of the world’s population is infected by TB, and is currently an epidemic in much of the world, causing mortality of about 1.5 – 1.8 million people per annum especially in less developed countries like Uganda. Indeed TB threat is endemic in lower and middle income countries, to the extent that an overwhelming majority of TB deaths (over 95 per cent) occur in these countries.

The day is partly a commemoration of the discovery of TB bacillus (a bacteria that is a major cause of tuberculosis) by Dr Robert Koch in 1882, a milestone which remarkably advanced TB control efforts and empowered the scientific community with regard to diagnosing and curing TB.
TB control is high in the contemporary global public health agenda and today, the world commits itself to end this deadly epidemic (among others like AIDS and malaria) by 2030, a health goal enshrined in the third global Sustainable Development Goal (SDG # 3.3).

This is a seemingly ambitious goal for a developing country like Uganda, given that we operate in a highly resource-constrained setting, and our health (TB related) performance indicators are still very poor and far from the “World End TB Strategy” ambition. The poor performance is reflected for instance in Uganda having one of the highest prevalence, mortality, and low success cases of TB, making it to be rated among the 22 TB high burden countries in the world. TB is the number one killer of HIV/Aids patients in Uganda due to TB-HIV/Aids co-infection. Uganda’s TB service delivery system is plagued with numerous gaps such as among others; poor access to diagnostic and treatment services and/or skewed diagnostic and treatment units in favour of urban areas. Rural health facilities suffer from poor state or lack of infrastructure to diagnose and treat TB and yet they are located in areas where TB is most prevalent. A small fraction of health facilities provide TB services, and there is dysfunctional TB referral system at district level.

Accordingly, it is indispensable to reverse these predicaments if the country is to move towards the 2030 target of ending the TB epidemic. According to the “End TB Strategy” by WHO, the goal of ending TB appears ambitious but it is feasible with employment of existing tools complemented by increased investments in universal health coverage and social protection. There are already some breakthroughs around the world to end TB for instance empirical evidence based on recent trials in Africa spearheaded by the TB Alliance reveal two new therapies that can potentially turn TB around. These therapies, which are products of research and innovation are able to cure all forms of TB in shorter time spans, including those that are the most difficult to treat. This is a great stride and Uganda can subscribe to this agenda, through investments in research and development (TB research agenda) in order to contribute to the “Unite to end TB” effort using innovative evidence-based approaches.

To reverse the TB predicaments that Uganda faces and make meaningful progress towards the global sustainable development aspiration of stamping out TB, public investments need to address existing gross TB service delivery gaps that are critical for TB prevention and treatment. This can be done by streamlining the following key intervention areas among others. First is prioritising TB research and innovation as well as instituting an effective routine TB surveillance system in the monitoring and evaluation framework of TB control programme. Second is raising public commitment in terms of funding TB control given that almost 20 per cent of national TB budget is unfunded. Third is improving access to TB diagnostic and care services given that TB is a poverty related disease which disproportionality affects the poorest, vulnerable and marginalised (especially urban slums and rural-based) segments of the population. This involves equipping lower level and rural health facilities to enhance their capacity to diagnose and fully treat TB as well as building health worker’s capacity through periodic training on Directly Observed Therapy (DOTS), strengthening community-based DOTS implementation to address TB service delivery needs of the disadvantaged or vulnerable sections of the population, full operationalisation of Diagnostic and Treatment Units in non-DOTS implementing health facilities, and operationalising district level TB referral system.

Overall, at policy level, it is paramount to fast-track revision of the phased-out (2010-2015) National TB Strategic Plan to provide policy guidance on different TB related public health interventions. This should take into account strategies to overcome barriers to access care; and the strategies articulated in the “global blue print” (WHO – End TB Strategy) adopted by the World Health Assembly in 2014, aimed at driving down TB deaths, incidence, and eliminating TB catastrophic expenditures by intervening in the three key areas for ending TB namely; effective policies and supportive systems, intensified research and innovation, and integrated patient-centered care and prevention.
Mr Odokonyero is a researcher at Economic Policy Research Centre – SPEED for Universal Health Coverage.