| BackgroundThe UN Millennium Development Goals for TB control specific requirements to the2015global tuberculosis morbidity and mortality50%lower than in1990. WHO raised the global Stop TB Strategy which stressed to absorb all of the health service providers to participate in the TB prevention and control. According to this concept, China adopt the public medical institutions and public health agencies called medical anti-cooperative strategy which insufficiently emphasized on the important role of comprehensive medical institutions for tuberculosis control. The various regions carried out a variety of prevention and control model and continuously optimize the sound.As a pioneer of medical anti-cooperation strategy, Shanghai established the TB management emphasizing the CDC, tuberculosis designated hospitals, community health service centers as the core, and General Hospital of universal participation. The initial results accepted by all parties. But at the same time, Shanghai’s TB control tasks are facing new challenges, such as drug resistance problem, with HIV infection, especially the increase of floating population and the aging of the more prominent issues. Therefore, to evaluate the management mode of TB prevention and of operation in Shanghai and explicit the problems under the new situation had an important practical significance, which can provide theoretical basis and exemplary role for other regions.ObjectiveTo understand the process of Shanghai TB prevention and management mode, analysis of the services carry out mechanism, operating characteristics and innovation exploration during implementation process of case detection, diagnosis, treatment and supervision of chemotherapy, health education and quality control assessment, operating characteristics and innovative. And we want to know the responsibilities of various agencies and the collaborative situation. To get the comprehensive summary of the advantages and problems of TB control mode during operation in Shanghai. In order to provide a scientific basis to improve TB control service system. MethodsQualitative and quantitative researches on7districts in Shanghai were used to carry out this study after the guidance of the "structure-process-Results" theory.Carry out in-depth interviews or focus group discussions investigation on health managers, all kinds of TB control staff and patients. Collected the specific information of TB prevention and control management model profiles and service delivery process. Understand the various stakeholders’views and opinions on the service capabilities, service providers, the institutional collaboration and process optimization during every process. Using the thematic framework analysis to induct the qualitative data.Collected the2005-2009regular report data in7districts. The descriptive analysis indicators including the case registration, suspected referral and cured outcome.Results1. Model profilesShanghai TB management model is based on city, district and community level organizations management agencies and the CDC management, designated hospitals for treatment, supervision of community health service centers as the core, and give full play to the general hospital patients found. Through cooperation with the education sector, the ministry of civil affairs and public security, the model form network coverage of "transverse to the edge, in the end vertical"2. Model mechanism(1) Case detection process:General hospitals at all levels to implement the detection of cases of non-centralized. Out-patient doctors and radiographers screening suspected patients by X-ray and sputum smear, strictly using triplicate to implement referral. Agencies through a district referral, counterparts referral, free shuttle service and other measures to ensure the patients go to designated hospitals for treatment. General Hospital TB line staff completed direct network reporting within24hours, community health service centers was responsible for implementing and tracking cases. Districts through the early discovery projects, the implementation of the daily recommended the formation of information systems and other methods to improve the case detection rate.(2) Diagnosis and treatment process:Designated hospital implemented sputum smear and culture examination for all suspected cases, and refer to the chest X-ray or CT scan results to confirm the diagnosis. Outpatient doctor carried out the basic standardized treatment to confirmed cases of in accordance with state regulations. Most of the designated hospitals to provide delay service, the doctor card issued to patients, medical personnel active phone alerts and other measures to ensure that the patient time and referral.(3) Supervision of chemotherapy process:Districts take full supervise management approach for patients relying on community health service centers and training of family supervisor. Community health service center took a variety of ways to conduct supervision and management of the patients like take home visit, telephone, make an appointment to the diversification of the community health service centers. Steering mode was divided into three categories including the management of the line doctors, general team management, compartmentalized integration of management.(4) Health education process:All agencies assume to the task of health education. They carry out targeted knot anti-propaganda to TB patients and their families, ordinary people, the gathered crowd, such as floating population/students, medical personnel. Missionary in the form of one-on-one lectures, posters, advertising, popular science lectures. Part of the district through the creation of healthy homes, set up volunteer teams, release creative gift to innovate the form and content of the mission.(5) Quality control and assessment process:CDCs have a clear assessment programs to evaluate and supervise the various medical institutions, which is routine. The strict quality control system, such as the regular meeting, ensures the effective control of TB. Internal assessment of the medical institutions can be completed by the form that the doctors special for TB regularly check for the work of clinicians, GPs with various programs support.3. TB prevention and treatment effectsBetween2005and2009. the trend of TB registration rate and newly registered rate of smear-positive TB was basically stable in the seven districts. The number of newly registered TB patients of the local residents population was stable or decreasing in the seven districts, while that of the floating population was increasing. In various project areas the rate of patients referred to the designated hospital has been improved, even up to90%in2009. The cure rate of smear-positive and the completed treatment rate of smear-negative patients have greatly improved. 4. Stakeholder assessment (1) service ability1) The number of TB control staff have meet basic needs, and the staff of designated hospitals and CDCs have the advantages in professional backgrounds. However, The quality of the general practitioners should be increased. Pre-service training and on-the-job training could enhance the awareness and capacity of the TB control staff. Sentinel clinics and community members were unsustainable.2) The mechanism which placed budget before pay and afford additional compensation could ensure TB special funds sustainable. The grant for Community Health Center could assure the basic work, but the allocation proportion was not clear, some counties supplied designated hospitals special compensation, but the amount is difficult to guarantee basic personnel expenses.3) The smear and radiographic equipment configuration in general hospitals and designated hospitals could meet the basic TB control requirements (2) service supply1) Timely and effective services were supplied by agencies, and the implementation of the safeguards measures has improved the efficiency, but the low compliance of some patients in the detection and supervision was not conducive to the service provider.2) With the higher requirements of TB control, the workload of doctors and the staff in TB control lines has been gradually increased, mainly in the too much report tables and the complicated reimbursement procedures。3) Part of the out-patient doctors could not do enough publicity and education and community visits were lack of clinical skills.(3) Institutional collaborationTaking the management of CDCs as the hub, relying on the diagnosis and treatment of the designated hospitals, and supported by the supervision of community health service centers, the general mode ensured smooth contact and coordination among the TB control agencies. However, There were some obstacles in the communication and collaboration between the three-level hospitals and TB control agencies and the intervention of the health administrative department was not ideal.(4) Management supportRewards to the general hospital doctors for case detection offered power to find the cases positively. And, the summary of diagnostic technology and information issues remained to be improved. The mode the line doctors were responsible for managing specially was the most prominent, but was difficult to fully implement. The problems that evaluation index calculation was not unscientific and the process indicators were ignored still exists.Conclusions1. The cooperation between prevention and Medical operation is the inevitable trend of TB control. Governments pay much attention to the TB control of Shanghai. And the advantages of the comprehensive prevention and control mode were more prominent with sound prevention network and standard institutional duty.2. Continuous and unobstructed coordination mechanism is conducive to the development of TB control.3. Human resources are the basis of TB control;4. Funding and compensation mechanism is an important guarantee for TB control work;5. The effective supervision and evaluation of TB control work can ensure the quality of service.6. Compliance of tuberculosis patients is the core issue of TB control and the compliance of the vulnerable groups such as the floating population is still facing challenges.Recommendations1. Government needs to further clarify the multisectoral responsibilities and supporting supervisory measures;2. Strengthen the Health Bureau implement the administrative intervention and coordination to medical institutions at all levels;3. To ensure the appropriate configuration and sustainable development of the workforce in the TB control;4. Identify and increase the compensation for the intensity of TB diagnosis and treatment of medical institutions;5. To carry out the social support for TB patients in all domains;6. Optimize tuberculosis waiver reimbursement methods and processes;7. Further strengthened to carry out education or training and implementation of impact assessment. |
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