TB Control Program in Afghanistan

REPORT OF ATTACHMENT (ASSIGNMENT) IN NATIONAL TUBERCULOSIS CONTROL

PROGRAMME, AFGHANISTAN

By:

Dr Khwaja Mir Islam Saeed

Training & Capacity Building Manager at Afghan Public Health Institute

Ministry of Public Health, Afghanistan

Fellow of FELTP 3rd Cohort, National Institute of Health, Pakistan

April-May 2010

TABLE OF CONTENT

Field Epidemiology and Laboratory Training Program, Attachment Report 2010 1

PREFACE..............................................................................................................4

INTRODUCTION....................................................................................................5

Background:.....................................................................................................5

National Tuberculosis Control Program.............................................................5

METHODOLOGY....................................................................................................6

Attachment Objective:......................................................................................6

Planned Activities:............................................................................................7

Proceedings:.....................................................................................................7

RESULTS...............................................................................................................8

Morning reports:...............................................................................................8

National TB task force meetings.......................................................................9

Quarterly Review Meetings...............................................................................9

Global Fund Round 8 Coordination Meetings..................................................10

Review of Polices, Strategies and other Documents.......................................11

National tuberculosis strategic plan (2009-2013)........................................11

Guideline for TB control Program in Afghanistan.........................................11

Lab guideline for control of tuberculosis......................................................12

Human Resource Development Strategic Plan (2010-2014)........................12

Other documents.........................................................................................12

Management of Tuberculosis: Training for Health Facility Staff...................13

Visiting Departments......................................................................................13

Surveillance, Monitoring and Evaluation Department..................................13

Laboratory and External Quality Assurance Department.............................14

Drug Management Department...................................................................14

Research Department.................................................................................15

Advocacy, Communication and Social Mobilization Department.................15

New Initiative Department...........................................................................15

Training Department...................................................................................16

Administrative Department.........................................................................16

Presentations provided/Attended....................................................................16

Prevalence of TB infection in Kabul Prison...................................................16

Evaluation of Public Health Surveillance System.........................................16

Evaluation of TB Surveillance System..........................................................17

TB lectures for new graduate doctors..........................................................17

SWOT Analysis................................................................................................17


Strength......................................................................................................17

Weaknesses.................................................................................................18

Opportunities...............................................................................................18

Threats........................................................................................................18

CONCLUSION.....................................................................................................19

RECOMMENDATIONS..........................................................................................19


PREFACE

The Field Epidemiology and Laboratory Training Program (FELTP) model has

been applied successfully in countries throughout the world. It has been started

in Pakistan since 2006 and it is planned to be started in Afghanistan very soon.

Field Epidemiology Training Program is a competency-based training and

service programs in applied epidemiology and public health that build public

health systems capacity in the countries in which they are implemented. In most

programs at least 75% of the training period is devoted to practicing

epidemiology in the field under the guidance of a mentor. The program aims to

support the strengthening of the public health system and to improve capacity in

applied epidemiology, public health surveillance and response, and public

health laboratories. While in class, fellows take courses in epidemiology,

communications, economics, and management and other main disciplines while

in the field, they conduct epidemiologic investigations and field surveys,

evaluate surveillance systems, perform disease control and prevention

measures, report their findings to decision-makers and policy-makers, and train

other health workers.

After establishment the program enrolled three cohorts from which the first one

is graduated and the other two are continuing their studies and assignment in

the program.

Being FELTP fellow of 3rd cohort, we are assigned, as attachment, to work in

national control programs in order to apply the knowledge and skills gained in

first five month contact sessions and at the same time become familiar with

public health approaches and activities used in the field. Ministry of Public

Health in Afghanistan is focusing on tuberculosis (TB) as main public health

problem and National TB control Program in coordination with other

stakeholders is the responsible for all issues regarding TB in the country.

Realizing the importance of TB as a main challenge in Afghanistan, I selected

this program as a place of my attachment. A specific Terms of Reference which

was developed by management were used as a reference for performing of

activities during assignment.


INTRODUCTION

Background:

Tuberculosis is a chronic disease which is caused by Mycobacterium

tuberculosis and remains a major cause of morbidity and mortality and a

significant public health issue worldwide. The global incidence of TB is

136/100,000 population at an average. This represents a total of 8.8 million new

patients and 1.6 millions deaths due to TB every year. According to WHO

estimates one infectious source would transmit infection by Mycobacterium

tuberculosis to 20 others during an average of two years before death or self

cure. Thus, it is very important to find TB patients as early as possible and treat

properly.

Afghanistan is the second highest TB-burdened country in the Eastern

Mediterranean Region and one of the 22 highest TB-burdened countries in the

world, with an estimated incidence of new sputum smear positive (TB SS+)

pulmonary tuberculosis, 76 per 100,000 population per year and all TB cases at

168/ 100,000 population per year. This means an annual incidence of 46000 for

all TB cases and 21,000 for TB SS+ (WHO, Report 2009, Global Tuberculosis

Control). An unusual predominance of TB in women persists. In the past for

many years, women comprised 68% of TB SS+ cases in Afghanistan. These

data clearly indicates that TB control is one of major problems in public health of

Afghanistan to be solved urgently.

The overall health status of Afghanistan demonstrates slow, but steady

improvement of the health care system. With infant mortality of 129/1000, under

five mortality of 191/1000 and maternal mortality of 1600/100000, the country is

focusing on a Basic Package of Health Services (BPHS). It was developed in

early 2003 and revised in 2005, based on disease burden and a primary health

care approach.

National Tuberculosis Control Program

The National Tuberculosis Control Program (NTP) was established in 1954 by

the Ministry of Health, with financial support from the World Health Organization

(WHO). The mission of the NTP is to reduce the impact of TB as a public health

problem in the country. Since 2002, under the new Afghan government, the


NTP has taken major steps to improve its managerial and technical capacity as

well as in securing external technical assistance and resources in order to

implement the DOTS strategy.

The MoPH has developed a new organizational chart that places the NTP

Directorate of communicable disease and under the General Directorate of

Preventive medicine. Basically, eight regional TB coordinators are responsible

for overseeing TB control in the country with 34 provincial TB coordinators who

oversee TB control in the provinces under the supervision of the Provincial

Health Directorates. For laboratory activities, NTP also recruited regional and

provincial laboratory supervisors and developed their capacity.

The estimated population that has access to DOTS facilities in Afghanistan has

steadily increased up to 97% by the end of 2007. However, this is a generous

estimate of population coverage; it assumes the whole population of a district is

physically covered, even if only one health facility in a district provides DOTS,

regardless of the actual number of people that have access to that facility.

The total number of health facilities utilizing DOTS has increased from 36

(representing 3.5% of the total) in 2001, to 991 (90%) by the end of 2007 and

1031 facilities in 2008. Referral of TB cases for diagnosis and treatment is

common amongst the BPHS and the EPHS as well as in the private and public

sectors.

METHODOLOGY

At the end of five month first contact sessions I was attached to National TB

control Program for one month. With a letter introducing me to NTP, I started to

work there at 18/04/2010 and ended my assignment on 27/05/2010. NTP is

located at west of Kabul within the campus of tuberculosis polyclinic. Following

objectives were observed in this assignment.

Attachment Objective:

Expose FELTP fellows to the planning and execution of national TB

control program focusing on activities prevention and control of TB as

priority public health problem

Assist the national TB control program in strengthening respective

surveillance component

Identify and implement collaborative projects with the technical

assistance from Center of Disease Control and prevention (CDC),


Atlanta

Planned Activities:

I was supposed to be attached with NTP on full time basis for a month from 5th

April to 7th May 2010. During the period of my attachment I was assigned to

work under the direct supervision of the national TB program manager but

would also required attending weekly de-briefing session with FELTP faculty on

every Friday. In case of need I was supposed to be deputed for outbreak

investigation on the request of surveillance department Afghan public health

institute. For best utilization we were proposed to be involved in the following

program activities.

Disease surveillance activities particularly assisting the concerned staff in

data compilation, analysis and interpretation.

Participation as observer in the routine meetings aimed at review of

activities/ progress, planning, development of guidelines, SOPs etc.

Development of action plans, planning and budgeting of various program

activities, rapid assessments.

Writing various program reports and prepare presentations.

Evaluation of surveillance arrangements, if required.

Development of study protocols and other projects proposals particularly

those requiring technical assistance from FELTP office and CDC,

Atlanta.

Proceedings:

Following main activities were conducted during one month attachment in

national tuberculosis control program.

Participation in morning report on Saturday and Mondays

Attending in TB task force meetings which was held weekly at

Wednesdays

Participation in provincial quarterly review meeting for medical doctors

& lab technicians

Participation in Global Fund Round 8 coordination meetings

Reviewing policies, strategies, guidelines, and training materials

Discussion of main activities with respect to each department with head

and staff of departments at NTP

Presenting the study on” prevalence and risk factors associated with


Mycobacterium tuberculosis among prisoners in Kabul Central Prison” at

national TB task force

Presenting the evaluation of TB surveillance system in Afghanistan at

national TB task force

Participation in half day session on tuberculosis for new gradate doctors

Direct observation of activities which was done during attachment at NTP

RESULTS

After leaving FELTP office with the aim of attachment to national TB control

program in Kabul, Afghanistan, FELTP and APHI at Ministry of Public Health

developed a letter and send to NTP showing our assignment based on pre-

determined TOR. The letter was a bit delayed and I started to work in NTP on

April 18th, 2010. Taking into consider the planned activities some actual

activities were performed during attachment. Brief description of those activites

is explained below.

Morning reports:

It is one of the important meetings which are secluded for Saturday and

Mondays each week. Mostly the internal issues regarding the program are

discussed in this meeting. That issue which is not resolved in this meeting is

shifted to TB task force meetings. In the meetings that I have attended following

mains issues were discussed.

Final draft of national TB guideline in Afghanistan

Supervision and monitoring of activities in the field

Delay in supervisory and salary payment

Issues regarding Drug Resistance Survey

Expediting the process of quarterly data collection and analysis

Community workshops and IEC material for health centers

Picture book of world TB day from all provinces

Human Resource Development strategy

Shortage and procurement of TB drugs to health centers

Issues regarding Round 10 Global Fund

Training plans

Communication and its importance in NTP


National TB task force meetings

This is a very fundamental decision making body regarding tuberculosis control

and prevention in Afghanistan which is held on Wednesdays every week. All

stakeholders including donors, non-governmental organizations (NGOs) and

government staff are participating in this official forum. Controversial issues are

put as agenda for this task force to find a better and joint solution for it. In task

forces that I attended was very interactive ones in which WHO, NTP, TB CAP,

NTP were participating. Here are some main issues which were discussed in

these task forces.

Financial support and medical doctors who working in National TB

Institute in Kabul

Perdiem policy for supervisory and monitoring visits which is performed

by NTP staff to provincial levels

IEC material and TV sports regarding tuberculosis

Human Resource Strategic Plan for TB in Afghanistan

Lac of lab technicians regarding microscopy in health centers

Advocacy, communication and social mobilization (ACSM) issues and its

approval by MoPH

Integration and modification of TB registers in health centers

Training of health staff and conduction of quarterly review meetings in

low secure provinces including Kandahar, Zabul and Urozgan.

Translation of NTP guidelines into local language

Presentations on TB infection in Central Prison, Evaluation of TB

surveillance system and first draft of HRD strategy

Quarterly Review Meetings

NTP has planned separate quarterly review meetings at provincial and regional

level and main issue emerging from these meetings is discussed in national

review meetings. Data collection, refining and feedback is done in these

meetings along with sharing of experiences, challenges and solutions. Some

technical training sessions are also included in these review meetings. In

meetings that I attended following issues were discussed.

Ensuring of quality on lab microscopy with respect to Microscope, lab

technicians and staining

Sample (sputum) quantity, its content and proper staining

Random collection of slides (20) from each health centers which is


supported by lab facility in order to recheck by national reference

laboratory

Discussion regarding high false positive (HFP), high false negative(HFN),

low false positive (LFP) and low false negative(LFN)

Discussion regarding AFB staining and labeling of smears

Technical discussion about smear pattern, thickness and evenness

Collection of quarterly lab reports from health facilities

Collection of quarterly data regarding case detection and treatment

TB Case detection and treatment and comparison of actual figures with

targets set by NTP

Register of tuberculosis for suspects, contacts, treatment and lab

examinations

Challenges of lab technicians regarding referring of suspects for sputum

examinations

Shortage of streptomycin as a main drug for treatment of category II TB

patients

Poor supply, supervision and monitoring of activities

Providing presentations regarding SOPs and IEC material

Motivation and commitment of staff in order to eliminate TB as a public

health problem in Afghanistan

Global Fund Round 8 Coordination Meetings

It was a meeting which was conducted every Wednesday prior to task force

meeting from 9:30 to 10:30. Stakeholders involved in global fund round 8 were

participating in these meetings and it was particularly focused on indicators

which are set for TB in global fund proposal. Following main issue were

discussed during these meetings in which I attended.

Urgent supply of streptomycin to provinces

Conduction of provincial quarterly meetings in southern provinces

Delays in sending of quarterly reports by less secure provinces

Overseas training ( SAARC) for TB technical staff

Delay of supervisory and salary payment by donors

Inclusion of nomads in TB registers as a requirement of global fund

proposal ( indicator)

Drug resistant survey as a pilot in six provinces

Teachers and schools students orientation of tuberculosis and


distribution of notebooks with messages of TB for primary students

Contact screening

Review of Polices, Strategies and other Documents

In last five years a set of documents have been developed and still in progress

by NTP and its supported stakeholders. Following are some main documents

which are reviewed during attachment taking into consider the time constraint.

National tuberculosis strategic plan (2009-2013)

It envisions a TB free country, with elimination of the disease as a public health

problem by 2050. The main goal is to reduce dramatically the country burden of

TB by 2013, in line with the Millennium Development Goals (MDGs) and Stop

TB partnership targets. It is based on last strategic plan (2006-2010) which is

focusing on main actions which is enshrined in stop TB strategy.

Pursue quality DOTS expansion and enhancement

Adapting DOTS to respond to TB/HIV, MDR-TB and other challenges

Contributing to health system strengthening

Engaging all care providers

Empower patients and communities

Enable and promote research

Guideline for TB control Program in Afghanistan

It is a document which guide all public health providers and clinicians how to

manage tuberculosis in the country. As a reference book it is newly developed

and NTP is trying to translate it in local language and distribute it to all TB

treatment centers to be used. Following are main issue which is discussed the

guidelines.

Tuberculosis and its overall control

National TB control Program

TB case detection and diagnosis

Role of laboratory in TB control

Treatment of tuberculosis

Prevention of tuberculosis

Recording and reporting system of tuberculosis control program

Monitoring and evaluation

Human resource development


Community involvement

New initiatives in tuberculosis control

Infection control

Lab guideline for control of tuberculosis

This guideline is developed for initial and refresher training of lab technicians

and their daily use. It starts with description of tuberculosis and modes of

transmission and afterwards continues with organization of lab activities prior to

sputum collection and examination. Smear microscopy procedures and quality

assessment system is the other main portion of this guideline. Assessment and

feedback to lab technicians is the last parts of this module. It is very useful

which facilitates daily affairs of lab staff al local levels.

Human Resource Development Strategic Plan (2010-2014)

A group of technical staff from NTP supporting by an international expert

developed and finalized the first draft of this strategy. Fortunately during my

attachment I had a chance to participate in the meeting when it was presented

to the stakeholders at NTP. Strategy is budgeted for five years and action plan

for first year is also developed. Following strategic interventions were suggested

in this strategy.

Action field: policies and strategies

Action field: NTP leadership for human resource development

Action field: financing of human resource development /NTP HRM

Action field: education at NTP

Action field: partnership for NTP

Action field: human resource management for NTP

Other documents

There are some other documents which is developed in NTP and due to

limitation of time I was not able to review them in detail. Some of these

documents are listed here.

Advocacy, Communication and Social Mobilization Strategy

Monitoring and Evaluation Strategic Plan

Public Private Partnership Strategy

TB/HIV guidelines

TBIS guidelines


Terms of References

Standard Operating Procedures

Management of Tuberculosis: Training for Health Facility Staff

It is a training package for facility staff which is prepared based on WHO

document (treatment of tuberculosis: guideline for national programs, 3rd edition

2003). Training department at NTP is using this package for national and

refresher trainings. Following are the main modules.

Introduction

Case Detection

Treat TB Patients

Inform Patients about TB

Identify and Supervise Community TB Treatment Supporters

Manage Drug and Supply for TB

Ensure Continuation of TB Treatment

Monitor TB Case Detection and Treatment

Field Exercise: observe TB Management

Reference Booklet

Visiting Departments

During attachment I had a chance to visit each department and discuss their

routine activities they were conducting. The staff including head of department

was interviewed in which success stories along with challenges discussed.

Following are the main activities they were conducting and the points I

discussed with them.

Surveillance, Monitoring and Evaluation Department

This department is responsible for overall case recording and reporting of TB

cases. They are managing supervisory and monitoring visits. They are

collecting, compiling and analyzing of quarterly reports to calculate indicators

regarding case detection, treatment outcome and AFB conversion. They have

developed the first draft of NTP national M&E plan and consolidate M&E

framework. They are busy with TB information system (TBIS) pilot and soon it

will be established at NTP. They are revising the reporting forms timely and

submit the report to EMRO online to be uploaded in global report. They are

providing annual reports. The main forms which is used form data recording and


reporting which is used by the program is listed here.

TB01- Treatment Card

TB02- Identity Card

TB03- Health facility TB Registers

TB04- Lab Registers

TB05- Request for Sputum Microscopy Exam Form

TB06- Request for Culture/Susceptibility Form

TB07- Referral/Transfer Form

TB08- Lab Quarterly Report

TB09- Health Facility Quarterly Report for case detection

TB10-Smear Sputum Conversion Quarterly Report

TB11-Treatment Outcome Quarterly Report

TB12- Requests for Drug and Lab Supplies and Reagents

TB13- Suspect Register

Data is collected quarterly but it is analyzed in detail (indicators calculation)

annually and annual report is produced and published.

Laboratory and External Quality Assurance Department

They have developed a lab network consists of national reference laboratory in

Kabul, six regional laboratories and almost 600 field laboratories. Quality

assurance for sputum smear microscopy is their high priority and it is supported

by JICA. Using lab supervisors at regional and provincial levels, they are

conducting supervisory visits in order to check the quality and provide on spot

guidance for technicians. They are conducting quarterly review meetings at

regional and provincial levels. In these meetings they provide technical

assistance and collect quarterly data on lab and compile sliders for cross

checking. In addition they are providing trainings sessions for lab technician

regularly based on their action plans. The other main activity at central level is

TB culture and drug sensitivity test.

Drug Management Department

This department is trying to ensure uninterrupted supply of anti-TB drugs and

medical supplies to health facilities in all regions and provinces. WHO and GDF

are the main donors in this regard. Head of drug department is trained in TB

drug management organized by WHO EMRO in Egypt and other trainings in

Kabul. They have calculated drug and medical supplies which is requirement for


all health facilities in a year. They are distributing drugs and medical supplies

according to their plan. Supervisory visits and monitoring covers the issue of

drug and medical supplies as well. Module for TB drugs and logistic system is

developed and approved by MoPH.

Research Department

This department is responsible for management and conduction of operational

researches regarding tuberculosis. According to research department the report

of study on knowledge, attitude and practice of sub urban population in Kabul

about TB is published. They have undertaken a project in collaboration with

SAARC to assess the HIV testing acceptability by TB patients. The analysis is

in progress and final report is awaited. They have investigated the role of

private pharmacies in treatment of TB patients in the central region and it is

under analysis by EMRO WHO. There are some projects granted by TDR,

EMRO/WHO and some other projects which are submitted; they are busy with

its management. Drug Resistant Survey is another main project which is going

on now as a pilot in five provinces in the country. Some departments including

lab department is involved in this important study.

Advocacy, Communication and Social Mobilization Department

The department has developed ACSM strategy to be finalized by MoPH.

Development of website is a practical measure for awareness through reflection

of news, reports, and photo galleries. They have developed some important IEC

materials for patients and their families, for health staff and general community.

There are some billboards and TV stop which is developed and used by this

department. They are conducting some orientation workshops for community

influential, religious leaders, teachers which have been very useful. In 2010,

they celebrated the world TB day in big functions and a picture book from this

gathering is under process to be published soon. They have developed the

STOP TB partnership which is supported by WHO and MoPH.

New Initiative Department

It is a new but active department within NTP and any issue which is new in

control of tuberculosis is managed by this department. They have developed

TB/HIV guidelines to be distributed to all health facilities. They are busy with

management of TB in prisons, Internally Displaced Populations (IDP) and


refugees. In addition department is trying to involve private sector by a pilot

project and they are also with management of TB in cross border areas.

Recently they have received fund for an important project on TB.

Training Department

It is a department which is involved in development of human resource for TB

control program. They have developed the first draft of strategic plan of human

resources for TB (2010-2014) to be approved by MoPH. Different sorts of

trainings is managed and conducted by this department in order to ensure

delivery of quality health TB care. They are responsible for conduction of

quarterly review meetings and awareness workshops. It’s in phase of transiting

to human resource development department.

Administrative Department

It is a department which is managing all managerial and correspondence

issues. Financial management, accounting, logistic and services, filing and

transportation is the responsibilities of this department.

Presentations provided/Attended

Taking the benefit of opportunity during attachment period at NTP, I provided

three presentations which were related to TB in national TB task forces. They

were welcomed by task force members and a question and answer sessions

was conducted at the end of each presentations. Following are the main points

of these presentations.

Prevalence of TB infection in Kabul Prison

As a requirement of MSc these at Aga Khan University, I completed one study

on prevalence and risk factors associated with TB infection among prisoners in

Kabul Central Prison ( Puli-Charkhi). Prevalence of TB infections was 55.7 %

and risk factors such as age, weight, monthly income prior to imprisonment,

duration of incarceration, area of accommodation per prisoner, personal

hygiene, content of food (meat and bean), low grade fever and night sweat were

associated with TST positivity. At the end of presentation the final report of

thesis was submitted to NTP which was received by worm welcomes. They

considered this study an important point for further study regarding TB in

prisons in Afghanistan.


Evaluation of Public Health Surveillance System

A framework for evaluation of public health surveillance system has been

developed by CDC which is very useful for evaluation of public health

surveillance systems. As have evaluated TB surveillance system, therefore, I

considered it very useful to present and orient task force members about steps

and attributes of surveillance system which is developed and explained by

CDC. They were very interested and the copy of presentation and guideline of

CDC was circulated later after presentation.

Evaluation of TB Surveillance System

As a requirement of FELTP program I had evaluated TB surveillance system in

the country in which HMIS and NTP was discussed. Both systems were

evaluated matching the attributes such as simplicity, flexibility, Acceptability,

data quality, sensitivity, positive predictive value, timeliness,

representativeness, and stability. They agreed with the evaluation scoring and

welcomed the recommendation which was provided to them. During Q&A

session they emphasized to strengthen recording and reporting, analysis and

feedback along with fully functional TB database.

TB lectures for new graduate doctors

A six week course was handled by APHI in which TB was given priority and two

sessions were allocated to it. In these two sessions the national TB control

program, national strategic plan, stop TB strategy and national TB guideline

particularly case detection and treatment was discussed in open forum.

Fortunately I also participated in these sessions and tool benefit of these

lectures.

SWOT Analysis

During one month of attachment I was able to identify the following strength,

weakness, opportunities and threats for National TB control program in

Afghanistan.

Strength

Comprehensive structure and position with MoPH

Qualified and experienced staff at central and provincial levels

Availability of strategic plan, guidelines and SOPs


Need based planning and decentralization of trainings

Expansion of TB management centers (DOTS) in last years

Quarterly meetings at provincial and regional levels

Establishment of TB Database (TBIS)

Involvement of private sector and public private partnership

Paying attention to gender and TB, cross border issues and HIV/AIDS, high

risk groups such as refugees, prisoners etc.

Weaknesses

Delayed recording, reporting and analysis of TB

Lack of protection fees for lab staff

Inconsistency in use of calendars at central and community levels

Inadequate number of microscopes at health facilities

Proper place for sputum collection, examination and storage

Availability of water and power at health facilities

Load of other lab tests than sputum exam in laboratories

Low refer of suspect by OPD to laboratories

Lack of capacity and motivation of staff including lab technicians

Inadequacy in supervision and monitoring

Shortage and poor supply of drugs and medical supplies

Improper management and supply of drugs, medical supplies and lab

reagents

Lack of coordination between NTP and other stakeholders at MoPH at

central and provincial levels

Opportunities

Political Commitment

Support of NTP by a group of donors

Efficiency of services as compare to government by NGOs

Availability of proper network of regional and provincial TB management

Launching of global fund round 10

Vertical program at central and integrated at local levels

STOP TB strategy

Threats

Staff turnover at facility levels


Probability of overlapping among donors in supporting NTP

Sustainability of program being supported by donors

Security disturbance in some provinces

Unavailability of allocated space and building for NTP

CONCLUSION

Although Afghanistan is one of 22 high burden countries and still tuberculosis is

a critical public health problem, however, as compare to 5 to 10 years earlier

there are much achievement which is credited to NTP. They have developed a

very acceptable structure for NTP at central and provincial levels and qualified

staffs have been recruited for these positions. They have been providing

technical trainings to staff involved in TB control and management. With

technical and financial support of stakeholders they have developed policies,

strategies, guidelines and standard operating procedures at different

department levels. There is a dramatic decline in burden of TB in the country

and all departments are jointly struggling to stop TB as a public health problem

in the country. Efforts regarding data management and epidemiology of

tuberculosis are in progress and I am optimist regarding surveillance of TB in

the country. Establishment of TB database at central level will solve many

challenges of planning, implementation and monitoring of TB related activities.

RECOMMENDATIONS

Taking into consider the period of attachment at NTP following recommendation

is provided for improvement and strengthening of the program.

National TB control program and TB polyclinic in which TB patients are

coming for treatment are working at the same building. There is a need to

have separate building for each entity. Fund should be raised for

construction of allocated building for NTP.

A cooperation agreement should be signed among donors that are

supporting NTP. It should cover recurrent expenditure of NTP for which no

one is responsible. It will avoid duplication of financial support and facilitate

managerial and technical issues of the program. Multiple donors are equally

a challenge and opportunity for the program. Their full involvement in all

planning, implementation and evaluation of activities will be a solution.

Capacity building for proper performance is must of NTP. They should

perform activities independently and sustainability should be guaranteed.


Technical trainings for health staff and lab technicians should be reinforced

and more facilities should be provided for central and provincial staff for

better performances.

Multiplicity of data recording, collection and reporting forms is less

acceptable by stakeholders. There is a need to conduct a workshop and

integrate the number of forms, particularly four register at health facilities

should be decreased to one or two registers.

It is required to develop a proper feedback mechanism in order to rectify the

problems raised at the field. Timely analysis of data and provision of

consistent feedback will improve the performance of the program. How to

provide quarterly feedback is a challenge for technical partners to assist

NTP in this regard.

Activities in Laboratory department have been conducting a bit in isolation

as compare to other departments, particularly surveillance department.

There is a need to strengthen coordination and integration of activities

among all departments.

TBIS is an important achievement of the program and it should be

strengthened. Training on data entry, analysis and production of report using

this software is crucial. It will facilitate planning, implementation and

evaluation of activities.

Protection fee was an incentive which was provided for laboratory and high

risk health workers in Afghanistan. Unfortunately it is not provided anymore

and admin department at NTP should find ways to add it on package of

benefits for those who need it.

Duality of calendars confuses the staff at central and provincials levels.

Based on HMIS experience the local calendars should be focused and this

issue will not create problem for donors and reporting period should be

developed based on their requirement.

Research department should investigate the reasons for predominance of

female with respect to proportion of TB cases in the country. Based on

analysis of quarterly or annual data the can generate hypothesis to be tested

regarding TB. They should submit at least five proposals for TDR yearly.

Creation of epidemiology unit under research department will facilitate the

issues.

Working for high risk groups such as prisoners, IDPs, refugees, MDR and

XDR, and HIV patients have been started and mostly they are at pilot


phases. They are the group who pump the disease to general community.

Specific budgeted action plans should be developed for each group in order

to control the disease among them. Coordination meetings with neighboring

countries by mediation of WHO will solve the problem of refuges screening.

Involvement of private sector is very much important. There is no one at

private sector to examine the sputum of patients for TB diagnosis and

treatment. For the time being we should start from private hospitals and

support them technically to detect and refer the cases. Some sorts of

motivation or incentives should be taken into account by more involvement

of private sector in order to refer the cases to TB to TB treatment centers.

Management of drug, medical supply and reagents for laboratories is

required to be strengthened. There should be plan of providing such

supplies based on their need and they should be supplied at least for three

month in advance. Shortage of drugs and supplies will jeopardize the fame

of the program.

Provision of all utilities such as water, gas, power, space and necessary

equipment will facilitate activities and motivate staff. It should be coordinated

with NGOs that are implementing the rule and regulation of MoPH.

Turn over of staff at local levels have face NTP to a challenge. Motivation

and incentives along with some agreement prior recruitment can decrease

turn over of staff.

Supervision and monitoring of activities at local levels is a good event which

is common at NTP. Unfortunately it is dependent on incentives and payment

by donors. It should independent of donor support and part of NTP

supported activities.

Sustainability of current performance when technical and financial support is

withdrawn is a big challenge. Retrospective analysis shows stoppage of

some activities when support is taken out. Technical and financial

supporters of NTP should find a mechanism to solve this problem and

ensure sustainability of program. Slowly and gradually provision of financial

provided by government would be one of solutions.

Conduction of more awareness campaigns particularly through TV spots will

inform communities regarding the disease and it will increase case

detection, treatment and prevention.

There is a rapid expansion of TB detection and treatment centers in the

country which is a good sign of improvement. Anyway the issue of quality of


these DOTS center is a question. Particularly the quality of sputum

examination which is done by lab staff and recording and reporting of data is

a real challenge. NTP in cooperation with donors and local NGOs should

strengthen the provision of technical trainings and equip them with facilities

which are needed for proper case detection and treatment. DOTS should be

expanded slowly and gradually to all health facilities by strengthening public

private partnership, urban and community based DOTS. Integration of BPHS

and EPHS in the name of Comprehensive Package of Health Services

(CPHS) by MoPH will assist NTP in application of its strategy.

Security has deteriorated some activities regarding performance of program.

Involvement of local and religious leaders, implementer NGOs, recruitment

of local residential staff, and strengthening community involvement will

facilitate and improvement the program.

Many guidelines and documents have been developed which is the strength

of the program, but still some are in progress and/or in the phase of

finalization. All departments should make efforts to finalize the documents

and translate it to local language to be useable and accessible by first line

health staff.


TB Control Program in Afghanistan

Documents

Transcript of TB Control Program in Afghanistan