Current Situation And Strategy For Tuberculosis Control In China

锘库槄鈪? Background:鈽匯eport on National Random Survey for the Epidemiology of Tuberculosis in 2000 showed the serious epidemic situation in China, while the TB case detection was onIn around 30%, far below the National TB Control Programme (NTP) goal of 70%. The new TB Control Project was launched in 2002, with the World Bank loan and DFID grant, over a period of 7 years. The project emphasizes raising the TB detection rate, according to the overall objective of China TB control and prevention. Social assessment is an effective way of identifying the constraints on TB detection, especially the barriers for the poor and vulnerable to accessing health care, and of identifying ways in which to improve TB health services.鈽呪叀. Research aims:鈽匒ssessing the understanding, beliefs, perceptions and stigma related to TB among different population groups and health care providers at different levels. Identifying the pathways of care seeking for both TB sufferers and TB suspects. Investigating the barriers experienced by poor and vulnerable populations in accessing TB services. Understanding the implementation of policies and strategies for TB control in study sites. Providing accommodation for increasing TB case detection and equity on accessing TB services.鈽呪參. Research Methods:鈽匱he study was carried out in Fujian, Henan, Liaoning and Xinjiang province in 2004, 3 counties in each province was selected. Both quantitative and qualitative methods were applied. Various stakeholders including health services users, providers and decision makers were investigated. 2560 residents, 889 TB patients and 907 suspects were interviewed with structured questionnaire. Focus groups discussion included 57 groups of residents and 22 groups of health providers, 155 health workers and administrators and 48 government officers were interviewed individually using prepared guidelines. Narrative individual interviews were carried out for 128 TB patients and 88 suspects. In addition, doctors' practice and interaction with patients were observed for 41 person-days.Ⅵ. Main Findings:1．Knowledge and attitude on TBThe study showed six-low and one-high awareness on knowledge and attitude of tuberculosis; they were low in recognition of TB, low knowledge on infection, treatment, length of episode, TB dispensary and TB control free-project; 'one high' was social stigma or discrimination from family or society.2．Pathway of Seeking CareOn average, 51% residents first choose village clinic for their symptoms, both township and village level was 79%. In Fujian and Henan more residents first choose village clinic, they were 69% and 79% respectively, more than half choose township health centre in Xinjiang because of weakness of village level. The choice happened in TB patients and suspects were similarly, 55-78% and 74-93% for both township and village level together. Convenience, cost, etc. were the main reasons for choice. Few people chose the TB dispensary.3．Delay in diagnosisIn this study, we use 'health seeking' delay to refer to a period of longer than three weeks from the onset of symptoms to the first visit to a health facility. 'Confirmed diagnosis delay' refers to period of more than two weeks from first health seeking activity to confirmed diagnosis. Nearly 30% TB patients had health seeking delay, 50% and more TB patients has Confirmed diagnosis delay. Many patients experienced several times visits before confirmed diagnosis, the median was 3-4, 17-30% patients had more than 6 times visits.4．Issues about referralTB control project request all TB suspect should be referred to TB dispensary to get further examination, treatment and administration. While people were often not referred to TB dispensaries and even when they were referred, it was not easy for them to attend the dispensary for diagnosis and treatment due to travelling expenses, geographical distance, time, and believe on TB dispensaries. This resulted in on average only 20% of TB suspects being successfully referred to the dispensaries.5．Adherence to treatmentFew TB patients had delayed in treatment, because the patients in this study were all those registered in TB dispensary. Adherence to treatment was good, less thank 18% patients has missing or interrupted taking medicine. About 50% patients reported be practised DOT, but much less were really practising DOT by doctors. Because of distance and because most village doctors are private practitioners and therefore need to earn their income so do not have time to visit patients for observation. Most doctors agreed that it was more practical to let family members supervise the patient's medication.6．Medical Expenditure:TB control project will provide free anti TB drugs and sputum test for 9 times and X-ray 1 time by TB dispensary. The health expenditure from community perception was fairly high, 2-5 times as real cost paid by patients. The health expenditure was account for 13-40% total expenditure of TB patient family. The deducted cost was only account for 20% of real cost, patients' burden was still high. Both quantitative and qualitative data showed besides high direct cost, there were some amount of indirect cost and the cost prior to diagnosis. The direct cost included examination and medicine for side-effect, and prolong length treatment that was not free.7．Poverty, gender, age and ethnic differences:The poor experienced longer delays, especially women, the elderly and the minority have less access to information about TB and the TB programme, less physical and economical ability, less social network and support, but more stigmas were more likely to face difficulties in accessing TB care.8．Low capability and behaviour of health providersDoctors had no enough knowledge on TB and lower capability to make diagnosis. This was related to lack of training and poor facility. Doctor might keep patients and did not referral patients in time because they need get revenue from fee for services. In those poor counties, less government budget for health sector and lower matching fund for TB control program impacted incentives and influenced doctor's behaviour.9．Financial and management issues Policy leaders and decision-makers saw programme funding as the critical issue influencing the degree of success of the TB control programme. The main issues highlighted as important by the policy makers were: less financial budget for health sector, the difficulty faced by providing matching funds. All those impacted providing incentives and training, therefore the capability and behaviour of health workers.Ⅴ. Recommendations:1．Carry out health promotion suitable for targeting populations and settings.Developing a long term work-plan for health education and health promotion, and monitoring the progress regularly to improve public knowledge and attitude. Appling reasonable contents and patterns for different group of people, eg. minority, aged and low educated people.2．Reduce the financial burdens for the vulnerable and poorMedical institutions should manage the administration of anti-side effect drugs.TB project fulfilled incentive to health workers to avoid mis-behaviour to generate revenue. Choose a few quality township health centres as TB prevention and control branches to reduce the indirect cost for TB patients spending on transportation and accommodation. Attention is required to the inclusion of the poorest and most vulnerable in alternative approaches to health financing, such as the development of health insurance schemes. Options for financing specialist TB services to reduce the costs of treatment to both smear-positive and smear-negative patients should also be considered in order to mitigate the negative impact of the direct costs of treatment to the poorest.3．Strengthen the training and management of health care providersStrengthen the training of township and village health care providers to improve and update their TB knowledge, to detect early TB suspects and make referrals to TB dispensaries promptly, and have confirmed diagnoses in time. Through performance management and financial incentives, motivate township and village doctors to treat and manage TB cases.4．Coordinate tertiary health care network in TB prevention and control, and treatment and monitoring workThe health administration sector should strengthen the management of the tertiary health care network in TB prevention and control, including development, implementation and monitoring of regulations. Attention is needed to strengthening the integration of TB specialist services and the general and primary health system and will require significant strengthening specialist capacity within these services.5．Raise case detection rate activelyDetect TB suspects through multiple channels, including via village cadres, via door to door visit and various level doctors .Support with diagnosing expertise treat TB patients promptly.6．Strengthen policy making, implementation and monitoring, encourage whole society join in TB control actionImproving recognition for local government, arrange enough matching fund, provide incentive strategy. More budget for health sector from central and provincial level, priority policy to poor region to increase the ability for TB control. Communication and coordination need to be improved, health system development and disease prevention and control need all society contributing.7．Recommendation on social assessmentSocial assessment would be applied from beginning to the end of China TB control project, applied in health education and promotion, applied in regular data collection.