Download Issue-based Guidelines

Thematic Guidelines
Tuberculosis Control
April 2007
Human Development Department
Japan International Cooperation Agency (JICA)
Preface
Tuberculosis is the leading infectious disease, and it is estimated that
approximately eighty billion persons are infected in the world.
Tuberculosis control is one of the foremost priority issues to be addressed in the
Millennium Development Goals (MDGs). That is, the goal is to “halt the expansion of
TB-infected persons by 2015 and then begin to reverse the incidence.” The Japanese
Government announced the Health and Development Initiative (HDI) pertaining to
“health and development” with emphasis on contributing to reaching the MDGs in 2005,
thereby expressing its commitment to cooperation for TB control.
In the past, JICA has rendered cooperation in a number of countries in the area
of TB control and successfully produced a steady and noticeable outcome in terms of
improving indicators of TB control. TB control is characterized by the facts that there
is globally standardized therapy, that hygienic, affordable, and effective treatment is
available even in developing countries, and that the measures to prevent the spread of TB
are closely associated with the treatment of each patient. Cooperation for TB control is
attracting increasing attention from the perspective of human security in that it
undoubtedly benefits people.
The Thematic Guidelines on TB control have been formulated with the aim that
the persons involved in JICA’s activities will be able to take more effective actions in the
area of TB control. That is, in the Guidelines, we review the general situation, trend of
aid, and the progress of approaches and schemes in TB control and then identify JICA’s
comparative advantage gained from past cooperation.
At the same time, we hope that you will make efforts to obtain and deepen
people’s understanding of JICA’s basic ideas on TB control by disclosing the Thematic
Guidelines to the public, for instance, through JICA’s knowledge site.
April 2007
Table of contents
Preface
Overall view of development issues in TB control
Overview
Chapter 1: Outline of tuberculosis and tuberculosis control .....................................
1 – 1: Prevalence and burden of tuberculosis ..........................................................
1 – 2: Disease called tuberculosis............................................................................
1 – 2 – 1: Infection with Mycobacterium tuberculosis and the onset of disease ...
1 – 3: Global initiatives for tuberculosis .................................................................
1 – 3 – 1: Global strategies to stop TB ..................................................................
1 – 3 – 2: High-burden countries ...........................................................................
1 – 3 – 3: Targets to stop TB..................................................................................
1 – 3 – 4: Expansion of DOTS and future prediction of TB .................................
1 – 3 – 5: Declaration of health emergency of TB in Africa .................................
1 – 3 – 6: New strategies from 2006......................................................................
1 – 4: Major international organizations for TB control..........................................
1 – 4 – 1: Stop TB Partnership...............................................................................
1 – 4 – 2: The International Union Against Tuberculosis and Lung Diseases
(IUATLD) ..............................................................................................
1 – 4 – 3: Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)........
1
1
2
2
4
5
6
7
7
8
9
10
10
11
12
Chapter 2: Approach to tuberculosis .........................................................................
14
2 – 1: Capacity development for DOTS implementation (Midterm goal 1) ...........
14
2 – 1 – 1: What is DOTS?......................................................................................
14
2 – 1 – 2: Components of DOTS ...........................................................................
15
(1) Political commitment with increased and sustained financing...................
16
(2) Case detection through quality-assured bacteriology.......................................16
(3) Standardized treatment, with supervision and patient support .........................16
(4) An effective drug supply and management system....................................
16
(5) Monitoring and evaluation system, and impact measurement ...................
16
2 – 1 – 3: Case detection and monitoring of treatment under DOTS ....................
18
2 – 1 – 4: Characteristics of DOTS .......................................................................
19
2 – 2: Capacity development for Beyond DOTS implementation for the vulnerable
population (Midterm goal 2) .........................................................................
20
2 – 2 – 1: Measures of greater importance under Beyond DOTS .........................
22
(1) Community DOTS .....................................................................................
(2) Urban DOTS...............................................................................................
(3) Public-Private Mix (PPM)..........................................................................
(4) TB/HIV (TB/HIV co-infection)..................................................................
2 – 2 – 2: Others ....................................................................................................
(1) Multidrug-resistant tuberculosis control (DOTS Plus)...............................
(2) Childhood tuberculosis...............................................................................
2 – 3: To summarize JICA’s past cooperation .........................................................
2 – 3 – 1: Technical cooperation............................................................................
2 – 3 – 2: Cooperation through training, etc..........................................................
2 – 3 – 3: Application of a modified DOTS strategy for each country..................
2 – 3 – 4: Grant aid ................................................................................................
2 – 3 – 5: Collaboration with volunteer projects ...................................................
2 – 4: Human security and tuberculosis ..................................................................
2 – 5: Gender and tuberculosis ................................................................................
22
23
25
25
29
29
31
32
34
34
35
35
36
36
39
Chapter 3: JICA’s cooperation policy on TB control ................................................
40
3 – 1: JICA’s cooperation policy on TB control ......................................................
40
3 – 1 – 1: Give priority to High Burden countries.................................................
40
3 – 1 – 2: Place an emphasis on the strengthening the quality of DOTS ..............
47
3 – 1 – 3: Support the Beyond DOTS strategy......................................................
47
3 – 2: Notes concerning JICA’s cooperation policy on TB control .........................
48
3 – 2 – 1: Cooperation primarily for human resource development, institution building
and system building (i.e., capacity development) .................................
49
3 – 2 –2: Secure the sustainability of the quality maintenance and improvement
entailed in the TB control project ..........................................................
49
3 – 2 – 3: Introduce a system modified for each country through implementing a model
project, etc. ............................................................................................
49
3 – 2 – 4: Make full use of the advantage of each scheme for effective cooperation
.............................................................................................................. . 49
3 – 2 – 5: Cooperation in closer partnership with international organizations and
aid organizations....................................................................................
50
3 – 3: Issues concerning the execution of JICA’s cooperation policy on TB control
53
3 – 3 – 1: To systematize cooperation programs to meet the needs and conditions of
each country...........................................................................................
53
3 – 3 – 2: Development and strengthening of input resources ..............................
56
3 – 3 – 3: To strengthen information collection and transmission
concerning DOTS ..................................................................................
3 – 3 – 4: To strengthen the implementation system to address new challenges...
Appendix 1: Major examples of cooperation
Appendix 2: Basic check items
57
58
Overall view of development issues in TB control
Goal of
development
strategy
Midterm goals
Sub-goals under
the midterm goals
Management capacity
development for TB
control
1.
Capacity
development for
DOTS
implementation
The government of
the
recipient
country
(implementing
agency) obtains the
ability to reach a
case detection rate
of over 70% and a
treatment success
rate of over 85%.
Development of capacity
for microscopic testing
Development of capacity
for logistics
2.
Capacity
development for
Beyond DOTS
implementation
for the
vulnerable
Capacity
development
for the implementation of
urban DOTS and hospital
DOTS
Capacity development
for the implementation of
public-private mix
(PPM) in DOTS
Capacity development
for TB/AIDS control
Examples of project activities
・To formulate TB control guidelines for
officials in charge of TB control in the
national, provincial, and prefectural
administration
・To support training for officials in charge
of TB control in the national, provincial,
and prefectural administration
・To strengthen the higher organization’s
roles of monitoring, evaluation, and
supervision of lower organizations
・To improve report system from officials in
charge at all levels
・To support coordination with other
development agencies
・To support collection of information about
valid TB control
・To formulate guidelines on sputum smear
microscopy
・To formulate a training module
・To support the establishment of an internal
quality assurance system
・To support the establishment of an external
quality assurance system
・To support the development of the national
procurement system of anti-TB drugs
・ To develop the record-keeping and
reporting system (TB registry system) at
the prefecture level
・To support switch-over to 4FDC
・To draw up guidelines for intervention with
defaulters on treatment and people with a
high risk of being infected
・To support the building of collaboration
among public organizations, private
organizations, and civil organizations
・To prevent hospital-associated infection
and to get hospitals involved
・To support the building of collaboration
between public organizations and private
organizations
・To draw up guidelines for PPM
・ To support the introduction of HIV
antibody testing among TB patients
・ To support the strengthening of
collaboration with HIV control
・To draw up guidelines for Community
DOTS
Capacity development
for rural TB control
Capacity development
for multidrug-resistant
TB control
Other
Capacity development
for tuberculosis in
childhood
・To support the formulation of a training
module
・To support reinforcing the development of
volunteers for medication confirmation
・To improve the capacity of bacterial culture
・To improve drug sensitivity testing ability
・To improve the management capacity of
the laboratory
To support the establishment of a contacts
examination system
Overview
Chapter 1: Outline of tuberculosis and tuberculosis control
1 – 1: Prevalence and burden of tuberculosis
Approximately one third of the total population of the world is infected with
tuberculosis (or TB). Each year, some nine million new patients 1 are added, and
approximately two million people die of TB. Serious problems are posed by the facts
that its burden is concentrated in developing countries and that the TB infection rate has
been expanding in parallel with the expansion and prevalence of the human
immunodeficiency virus (or HIV) in sub-Saharan Africa. In fact, effective and feasible
TB treatment is available even in developing countries. Thus, it is possible to cure TB
completely with affordable therapy. On the other hand, a challenge is that the TB
burden is not yet on the decrease due in part to constraints of systems and human
resources.
1 – 2: Disease called tuberculosis
TB is an infectious disease in which the person is the source of infection. Its
pathogen is Mycobacterium tuberculosis. The onset of tuberculosis, that is, symptoms
observed in the TB-infected person (or carrier), is followed by an infection phase of two
years on average. It is projected that during this phase, one patient infects from ten to
thirteen persons per year. After the onset, half of patients will die after five years
unless they are treated properly. A feature of TB is that Mycobacterium tuberculosis
goes into dormancy as long as the infected person is in good health, but it recurs when
he/she is in ill health.
1 – 3: Global initiatives for tuberculosis
TB control as well as HIV/AIDS control has been intensified in international
coordination. Since the 1990s, the World Health Organization (WHO) has been
vigorously addressing the issue of TB control: it established global goals; it declared TB
a global health emergency; and it formulated a framework of global TB control
strategies. TB control is also set as one of the priority issues in the Millennium
Development Goals (MDGs) and the Health and Development Initiative (HDI). With
respect to specific TB control measures, since the WHO proposed a package of
1
In the Guidelines, a patient is defined as a person who becomes infected with Mycobacterium tuberculosis and
shows its symptoms.
i
strategies called Directly Observed 2 Treatment with Short-course Chemotherapy
(DOTS 3 ), many countries have adopted measures in order to introduce and diffuse the
DOTS strategy.
1– 4: Major international organizations for TB control
The Stop TB Partnership is constituted of WHO, various nations, private aid
organizations, and NGOs. The Partnership looks into the problems pertaining to TB
control and their solutions and tries to mobilize resources from related organizations.
To put it in more concrete terms, for instance, it announced global TB control strategies
for the period from 2006 to 2015. Besides, the International Union against
Tuberculosis and Lung Diseases (IUATLD) carries out similar activities as one of the
chief international aid organizations. The Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM) also provides aid to the area of tuberculosis. These
organizations have been taking actions for TB control under the global cooperation
system to achieve the MDGs in a concerted effort.
Chapter 2: Approaches to tuberculosis
2 – 1: Capacity development for DOTS implementation (Midterm goal 1)
DOTS means a package of strategies that contain a series of actions to be
carried out by executive organs in order to detect, diagnose, and treat contagious TB
patients. DOTS originally means treatment in which drugs are administered to patients
in front of a medical professional (that is, under direct observation). However, its
definition has been broadened and globally used as an abbreviation to connote a
package of TB strategies consisting of five components including logistics such as
testing reagents and anti-tuberculosis drugs and the development of human resources so
that TB treatment can be continued. The DOTS strategy was originally developed
based upon the failure of TB control before the 1990s. It is the first TB control
strategy whose validity has been established in developing countries. Hence, TB
control now follows the DOTS strategy worldwide.
In the Thematic Guidelines, which present the cooperation policy of the Japan
International Cooperation Agency, three sub-goals are set under the midterm goal as a
2
In the meeting of STOP TB of 2006, a group of patients pointed out that the phrase “direct observation” was
inappropriate. Thereafter, the phrase “medication confirmation” has been gradually replacing the former.
However, in the Guidelines, the former phrase is used.
3
An interpretation of the term “DOTS” goes beyond its normal definition of “short-term chemotherapy under direct
observation.” That is, it is used among people related to TB control as a term that expresses a “strategic package”
inclusive of management, microscopy, and logistics.
ii
result of classifying the output of the Project Design Matrix (PDM) of projects that
JICA has implemented in the past and also in reference to the five components of
DOTS. 4
2 – 2: Capacity development for Beyond DOTS implementation for the vulnerable
population (Midterm goal 2)
The DOTS strategy forms the foundation of TB control, and is the globally
standardized approach. Hence, there are cases in which additional different measures
need to be undertaken in order to deal with the diverse conditions of each country. In
developing countries, there are new needs for implementing a variety of stepped-up
actions in addition to the DOTS strategy. This is because a sufficient number of public
medical service centers have not been established to cover the entire nation and because
HIV has been extensively spreading. For instance, Community DOTS and TB/HIV
control, which come under the Beyond DOTS strategy, have been developed and proven
effective.
It is essential, however, to study carefully before introducing Beyond DOTS
whether DOTS, which lies at the heart of TB control, has been properly implemented.
2 – 3: To summarize JICA’s past cooperation
JICA has made effective use of various schemes such as project-type technical
cooperation and training courses as a package. Furthermore, it has provided aid to
strengthen the TB control of each country in close partnership with the United States
Agency for International Development (USAID), the World Food Program (WFP), the
World Bank (WB), the Asian Development Bank (ADB), and other non-governmental
organizations (NGOs). Since the 1990s, JICA has focused upon the application and
development of the DOTS strategy in many countries.
In particular, JICA has produced excellent results in its cooperation for capacity
development including the development of necessary human resources, institutional
building, and system building in order to strengthen the abilities of the recipient country
to operate and manage DOTS under its national TB control program.
2 – 4: Human Security and tuberculosis
4
In the “Global Plan to Stop TB for 2006-2015” announced in January 2006, Beyond DOTS is explained as a part of
DOTS. It is assumed that this interpretation will be accepted more and more in the future worldwide. On the
other hand, the Guidelines have been prepared as reference material for JICA’s staff. Hence, DOTS and Beyond
DOTS are separately presented so that the situation can be explained clearly and simply since it is reasonable to
consider that DOTS still lies at the heart of TB control.
iii
Tuberculosis has been placing a heavy burden especially on the poor in
developing countries. Hence, cooperation for TB control addresses the issues integral
to Human Security, i.e., “freedom from fear” and “freedom from want.” The DOTS
strategy is an approach that has translated human security into concrete actions as
indicated by the fact that support is directly extended to each patient without fail. On
the other hand, the poor often find it difficult to have access to public medical services.
As a result, it is often the case that the strengthening of only DOTS that provides TB
control services through public medical institutions is insufficient. In order to give due
consideration to the poor, actions such as Community DOTS included in Beyond DOTS
need to be implemented so as to create an environment in which patients from any
social strata have easy access to medical care service.
2 – 5: Gender and tuberculosis
Tuberculosis poses a menace to women. That is, the number of women who
die of TB is greater than their deaths related to child delivery. TB is certainly not a
disease that inflicts a burden only upon women. However, women are more exposed
to the risk of being infected and vulnerable to the quick progress of the disease probably
for the following reasons: the environment surrounding women is very disadvantaged in
developing countries; more women tend to assume the responsibility of taking care of
TB patients at home; and women, in particular, have greater difficulties in access to
public medical services.
Chapter 3: JICA’s cooperation policy on TB control
3 – 1: JICA’s cooperation policy on TB control
JICA’s cooperation policy on TB control consists of the following three pillars:
① To set priority countries (high-burden countries, high-incidence countries, or
countries that lag behind in TB control)
Aid priority is given to those countries that suffer from a heavy burden of TB and
lag behind in TB control.
② To give overriding priority to the qualitative reinforcement of DOTS
In JICA’s cooperation, the highest priority is given to reinforcing the DOTS strategy
that is in the hub of TB control, thereby giving a boost to all TB control actions.
③ To assist the Beyond DOTS strategy
From the perspectives of Human Security and effective reinforcement¥/ of TB
control, JICA shall render necessary support to strengthen “Beyond DOTS” based
iv
upon the way in which DOTS has been implemented in each country and the
conditions peculiar to the country.
JICA will provide these priority countries as stated in ① with cooperation of ② or
③ according to the conditions of each country, or it may give cooperation that contains
both components selectively chosen from ② and ③. In other countries than those
listed in ①, JICA also has a possibility to carry out activities that partially entail TB
control as a part of measures against other diseases including HIV/AIDS or regional
public health projects, although projects that principally focus on TB control will not be
implemented. Besides, JICA will extend cooperation for developing the general
capacity of people involved in TB control in other countries than those listed in ① in
such way as group training courses held in Japan.
3 - 2: Notes concerning JICA’s cooperation policy on TB control
JICA will adopt the following five approaches in its cooperation in the area of
tuberculosis. JICA regards these approaches to be important to TB control based upon
its experience and also the fact that it has a comparative advantage.
① To focus upon capacity development with the chief aims of human resource
development, system building, and institutional building.
② To consider the maintainance or improvement of the quality of TB control program,
and the assurance of the sustainability of the system.
③ To apply a system modified to suit each country through such way as implementing
a model project
④ To provide cooperation in a package of various schemes
⑤ To provide cooperation in closer partnership with other international organizations
and aid organizations.
3 - 3: Issues concerning the execution of JICA’s cooperation policy on TB control
JICA focuses upon improving the following three issues:
① To systematize cooperation programs suited to the circumstances of each country
② To improve and strengthen input resources
③ To strengthen the collection and transmission of information
v
Chapter 1: Outline of tuberculosis and tuberculosis control
1 – 1: Prevalence and burden of tuberculosis
Tuberculosis (TB) is an infectious disease caused by Mycobacterium
tuberculosis. It is the leading disease among infectious diseases caused by a
mono-pathogen. The World Health Organization (WHO) estimates that over one third
of the world’s population (equivalent to some 1.9 billion persons) has already been
infected and that there are about nine million new TB cases and nearly two million TB
deaths each year. 1 About half of patients die after five years if left untreated. This is
essentially a curable disease if it is treated properly. Despite the availability of
affordable drugs for its treatment, neither the number of TB patients nor TB deaths have
decreased due to various factors. 2
Big problems are that the burden of TB has been concentrated in developing
countries and the number of TB patients is on the increase particularly in sub-Saharan
Africa in parallel with the spread of human immunodeficiency virus (HIV) (as shown in
Figure 1-1). More than 95% of TB patients and over 99% of deaths are concentrated
in developing countries.3 Factors to quicken the epidemic of TB are variable including
poverty, increasing population, social unrest, and gravitation of population towards
urban cities. Similarly, approximately 30% of HIV-infected persons die of TB
throughout the world. It is reported that the leading cause of death is tuberculosis
among HIV-infected persons. 4
The dark green parts of Figure 1 – 1 indicate areas where the TB incidence rate
is high. That it is concentrated in sub-Saharan Africa is evident from the map.
1
WHO Report 2007: Global Tuberculosis Control Surveillance, Planning, Financing.
(Ishikawa, Nobukatsu: How should Japan be involved in the global TB problem? 1999, Vol. 80, No. 2; 89-94,
2005)
3
Dye, C: Global Burden of Tuberculosis, JAMA, 1999; Vol. 282, No. 7
4
Tuberculosis Research Institute: DOTS stories of Three Kingdom : fighting against tuberculosis in developing cou
ntries : DOTS strategy and Japan's internatinal cooperation
2
1
Figure 1 – 1: Estimated TB incidence rate by country (2005)
Source: WHO Report 2007: Global Tuberculosis Control Surveillance, Planning Financing
1 – 2: Disease called tuberculosis
When a person becomes infected with Mycobacterium tuberculosis and
develops its symptoms, his/her lungs are corroded with TB over a period of from
several months to several years. The tissues of the corroded lungs are discharged out
of the body together with M. tuberculosis, which become the source of infection for
people in frequent contact with the patient. The TB condition gradually progresses.
That is, a respiratory disorder is caused, and mycobacteria invade other parts of the body.
In some cases, they destroy brain and internal organs, thereby leading to death.
1 – 2 – 1: Infection with Mycobacterium tuberculosis and the onset of disease
(1) Route of transmission
Tuberculosis spreads with aerosol droplets (droplet infection or airborne infection).
M. tuberculosis invades the lungs and is discharged together with sputum or mucus.
Other persons inhale the bacteria, thereby becoming infected.
(2) Loop of TB infection (Infection, onset of the disease, and spread)
Mycobacterium tuberculosis invades the body, whereby the passive (acquired)
immune system goes into action and antibodies are formed. This stage is called
2
“being infected.” 5 TB infection leads to “full-blown TB” in about 10~20% cases
without being naturally cured.
When the active TB disease progresses further, M. tuberculosis is discharged out
of the body, thereby infecting other persons around (being in a state of sputum
smear positive). This state continues for about two years on average. During this
period, one TB-infected person may infect 10~13 other persons on average per year.
TB kills about half of those infected, if not properly treated. Approximately
20% of them continue to discharge M. tuberculosis even after five years, whereas
about 30% are naturally cured (sputum smear negative: no M. tuberculosis being
found by sputum smear microscopy). 6
There are some risk factors that induce the onset of full-blown TB disease from
the infection stage. They include diabetes, slender physique, malnourishment,
aging, and heavy smoking as well as factors that weaken cellular immunity such as
HIV infection and immunosuppressant drug therapy.
5
More specifically, Mycobacterium tuberculosis that has reached the end of the lung tries goes farther into the body.
Then, the immunity that is passively triggered begins to function (non-specific immunity by macrophages). If M.
tuberculosis defeats this immune system, an order is given to manufacture antibodies from helper/inducer T cells
(putting active immunity into action; non-specific immunity). At this phase, it is defined that “the person has been
infected with TB.”
6
Aoki, Masakazu: A study of tuberculosis useful for daily treatment and duties; p. 35, April 2002
3
Figure 1 – 2: Infection and the onset of disease
Droplet nuclei
M. tuberculosis
Droplet
M. tuberculosis
Invasion of M. tuberculosis into the lungs
Attached to the lungs
and discharged by
ciliary movement
Invasion into the tip of the lungs
Macrophages
Innate immunity goes into action.
Acquired (cellular) immunity goes into action.
If innate immunity is
unable to suppress M.
tuberculosis
Infected with
M. tuberculosis
Immune system is
unable to suppress
M. tuberculosis
Immune system
suppresses M.
tuberculosis
Not manifested
throughout the life
Primary infection
Onset (Active TB)
Onset
from past
infection
1 – 3: Global initiatives for tuberculosis
In TB control, there is global collaboration. Under the “Stop TB Initiative”
led by the WHO and constituted by national governments, related international
organizations, aid organizations and NGOs, the “Stop TB Partnership” has been
addressing the issue of TB control and making efforts to funnel aid from countries into
TB control.
In particular, since 1994, the principal focus has been on the DOTS strategy.
In a new strategy paper for the following decade (Global Plan to Stop TB 2006-2015)
formulated in 2006, it was proposed to scale up various actions that had been classified
under the Beyond DOTS strategy in addition to ensuring the implementation of DOTS.
(Refer to 2 – 1: DOTS and 2 – 2: Beyond DOTS in Chapter 2.)
4
1991
General Assembly of the WHO “to achieve an 85% cure rate and a 70% detection
rate by 2000”
1993
WHO declared “tuberculosis a global emergency.”
It warned that TB had inflicted extensive health damage in many areas of the world
due to the neglect of TB control, the spread of HIV infection, and the emergence of
multidrug-resistant strains of M. tuberculosis.
1994
The WHO announced the Framework for Effective Tuberculosis Control.
1995
The WHO adopted the DOTS strategy.
1996
The 24th of March was made World TB Day .
1998
The Stop TB Partnership was founded (the London Conference).
March 2000
Amsterdam Declaration (Ministerial Conference on Tuberculosis)
July 2000
G8 – Okinawa Infectious Disease Initiative: IDI
October 2000
The WHO stipulated the Millennium Development Goals (MDGs) at the General
Assembly.
2001
The Washington Commitment was adopted (50/50), 7 (Stop TB Partners’ Forum)
2002
The Global Fund to Fight AIDS, Tuberculosis and Malaria began assistance.
2005
Health and Development Initiative (HDI) by the Japanese Government
2006
The WHO announced the Global Plan to Stop TB for 2006-2015.
1 – 3 – 1: Global strategies to stop TB
TB was neglected over a prolonged period of time in a great number of
countries. Even the WHO paid very little attention. As a result, it continues to be the
leading killer in developing countries. At the same time, the circumstances of
advanced countries have changed as well. That is, they are witnessing a resurgence of
TB health damage that was once under control. 8 The 44th World Health Assembly of
the WHO (1991) set two key global targets to be reached by 2000: 70% of existing (or
estimated) acid-fast bacilli smear-positive TB patients will be detected, and 85% of
newly detected smear-positive TB patients will complete the course of treatment
regimen (to succeed in treatment) so that TB is paid higher attention.
In 1993, two years later, the WHO declared TB a public health emergency and
7
The governments of high-burden countries and Stop TB partners came together at the World Bank in Washington
and the framework of partnership and the Global Plan to Stop TB were approved. “50/50” indicates that the Forum
used 50 as the keyword and set the goals to be achieved within each period of 50 years, 50 months, 50 weeks, and 50
days.
8
The circumstances of advanced countries have changed due to a variety of factors including multidrug-resistant TB
cases detected in New York from 1991 to 1993 and an increasing number of HIV/AIDS-associated cases. (Ishikawa,
Nobukatsu: World’s TB, Japan’s TB. J. Nippon Med SCH 2000; 67(5)”
5
made a recommendation that its member countries should address TB control as the
overriding priority issue, because it was found that the damage caused by TB had spread
to many areas in the world due to the neglect of TB control, the spread of HIV, and the
emergence of multidrug-resistant strains of Mycobacterium tuberculosis (in (1)
Community DOTS under Section 2 – 2 – 1 in Chapter 2). Subsequently, the WHO
formulated a framework of global strategies in order to develop more effective and
potent measures. 9 It later grew into a package of strategies called DOTS.
DOTS originally means that medication is supervised under direct observation
in a short course of chemotherapy. However, currently, DOTS has been transformed
into a concept. That is to say, it is now globally used as an acronym to indicate a
package of TB control strategies consisting of the following five components on which
the WHO lays emphasis as TB control measures in developing countries:
① Political commitment with increased and sustained financing
② Case detection through quality-assured bacteriology
③ Standardized treatment,with supervision and patient support
④ An effective drug supply and management system
⑤ Monitoring and evaluation system,and impact measurement
(Chapter 2 discusses the strategies in depth.)
Subsequent to the development of DOTS, the WHO made it a policy to seek
scientific evidence to prove that DOTS was the most cost effective among various
disease control measures and health administrative measures. Based upon the
evidence, the WHO raised funds from donors under the initiative adopted by the WHO,
etc., thereby expediting the adoption of the DOTS strategy globally.
1 – 3 – 2: High-burden countries
In March 1998, the First ad hoc Committee on the Tuberculosis Epidemic was
held in London. There, public health experts got together from all over the world and
introduced the fact that 80% of estimated TB patients of the world were concentrated in
22 countries. In the same Committee, it was pointed out that the delay in the progress
of DOTS in those 22 countries had an adverse effect on the expansion of DOTS in the
world. Hence, the 22 countries were regarded as high-burden countries, and it was
decided to give top priority to implementing DOTS in these countries (Refer to Table
3-2 (right side) in Chapter 3).
9
WHO: Effective Framework for Tuberculosis Control, 1994
6
1 – 3 – 3: Targets to stop TB
Despite the efforts to strengthen DOTS, it was difficult to achieve the goals to
“reach an 85% treatment success and a 70% case detection rate of TB by 2000.” As a
result, the year was put off to 2005. The Stop TB Partnership (an international
organization in which all nations and private organizations fight against the crisis of
tuberculosis in a concerted effort) was formed subsequent to the abovementioned
London Conference. (Section1 – 4 – 1: Stop TB Partnership discusses the issue in
detail.) The Partnership announced the “Global Plan to Stop TB 2001-2005” that
aimed to achieve these targets by 2005 and halve TB cases by 2010. 10
The Millennium Development Goals (MDGs) address the issue of tuberculosis
under Target 8 “Halt by 2015 and then begin to reverse the incidence of malaria and
other major diseases” in Goal 6 “Combat HIV/AIDS, malaria, and other diseases.”
Indicators include “23. Prevalence and death rates associated with tuberculosis” and “24.
Proportion of tuberculosis cases detected and cured 11 under directly observed treatment
short-course DOTS (internationally recommended TB control strategy).” 11
The Japanese Government announced the “Health and Development Initiative”
(HDI) and its commitment to reaching the targets associated with health in the MDGs. 12
1 – 3 – 4: Expansion of DOTS and future predictions of TB
As of 2004, 183 countries out of 210 countries have adopted DOTS, and DOTS
covers 83% of the world’s population (that is, people living in the regions where DOTS
is implemented). 13
Nonetheless, there is still a long way before reaching the global targets of
achieving “70% case detection and 85% treatment success rates.” The regions where
the DOTS strategy has been adopted have reached a treatment success rate of 82% of
new sputum smear-positive patients, 14 on the other hand, case detection hovered at a
low rate of 51% by 2001 and rose to 64% in 2004. 15 It is proven that the outcome of
TB treatment improves under the DOTS strategy, but the WHO Report 2006 maintained
that a problem was that the case detection rate had not risen sufficiently and predicted
10
WHO: Progress Report on the Global Plan to Stop Tuberculosis, 2004
A sputum smear positive patient who has been confirmed that he/she has achieved the final goal of treatment and
who had once turned sputum smear negative earlier.
11
WHO: http://www.who.int/mdg/goals/goal6/en/index.html
12
Ministry of Foreign Affairs: http://www.mofa.gp.jp/mofa/gaiko/hoken/mdgs/kokensaku.html
13
WHO Report 2006: Global Tuberculosis Control, Surveillance, Planning, Financing
14
WHO: 72% in the African region, 75% in the European region: The low treatment success rate is caused by HIV
infection in the former, whereas it stems from drug resistance in the latter. At the same time, it has been pointed out
that the result of TB treatment has not been sufficiently monitored (that is, failure in DOTS). (WHO Report 2006:
Global Tuberculosis Control, Surveillance, Planning, Financing)
15
WHO Report 2006: Global Tuberculosis, Control, Surveillance, Planning, Financing
11
7
that the goal of reaching 70% could be attained by 2013 if TB control was not
intensified in the near future. 16
Figure 1 – 3: Progress toward the 70% case detection target
80
WHO target 70%
Case detection rate, smear-positive cases (%))
70
The total number of
smear-positive
cases
notified
(DOTS
and
non-DOTS) of estimated
cases (%)
60
50
It is predicted that the
target will be reached
by 2013 if progress is
made at the average
(%) annual increment
taken from 1994-2000.
40
30
DOTS begins
20
The number of new
smear-positive cases
notified under DOTS of
estimated new cases
(%)
10
01990
1995
2000
year
2005
2010
2015
Source: WHO Report 2007: Global TB Control Surveillance, Planning, Financing
1 – 3 – 5: Declaration of health emergency of TB in Africa
The WHO declared TB a public health emergency in pertinence to the
extensive prevalence of TB in Africa in August 2005 at the Regular Meeting in which
ministers of Health participated from 46 African member countries. 17 In Africa, the
numbers of both TB-infected persons and deaths have been rapidly increasing due to the
spread of AIDS. From a global view, TB imposes its burden mostly in Africa. In
general, in regions other than Africa, the TB epidemic has been stable or on the decrease
and it is believed that the MDGs of halving the prevalence and mortality will be attained
by 2015. On the other hand, circumstances in Africa have been deteriorating and the
WHO came to the decision to make this declaration based upon the assumption that the
goals could not possibly be achieved by the situation in Africa.
16
17
Final Report of the 2nd Meeting of the DOTS Expansion Working Group. WHO/CDS/TB.2002.303
WHO: http://www.who.int/tb/features_emergency_declaration/en/index.html
8
Throughout the world, there are over nine million new cases and about two
million deaths per year. Out of these, Africa carries the burden of 2.4 million new
cases and 540 thousand deaths. Despite the fact that Africa shares merely 11% of the
world’s population, one out of four TB patients and TB deaths arise in Africa. The
WHO called for mobilizing funds to scale up the DOTS strategy and arrest the spread of
tuberculosis and HIV. 18
1 – 3 – 6: New strategies from 2006
Under recent African circumstances in which the case detection rate still hovers
low and the TB burden has been expanding, it is argued that it may be necessary to
move farther from the conventional emphasis on smear-positive TB (under DOTS with
the chief aim to stop TB by focusing upon the detection and treatment of patients who
have contracted the most contagious form of TB). To put it another way, it may be
required to take stepped-up measures to deal with the issue of persons who are
co-infected with TB and AIDS and expand the use of private medical institutions. The
conference of the Stop TB Partnership Working Group held in October 2005 (to be
discussed in depth under “1 – 4 – 1: Sop TB Partnership”) issued the “Global Plan to
Stop TB for 2006-2015,” which aims to scale up TB/HIV control measures,
Public-Private Mix (PPM) measures, and multidrug-resistant TB control measures
etc.. 19
The “Global Plan to Stop TB for 2006-2015” includes the following targets in
order to achieve MDG6.
MDG6. Target 8: “Halt by 2015 and then begin to reverse the incidence of malaria and other
major diseases.”
In order to achieve this:
(By 2005: detect at least 70% of new sputum smear –positive TB cases and cure at least 85%
of these cases)
By 2005: To be sustained or exceeded by 2015: At least 70% of people with infectious TB
will be diagnosed and at least 85% of those diagnosed will be cured.
By 2015: The global burden of TB diseases (disease prevalence and deaths) will be reduced
by 50% relative to 1990 levels. The number of people dying from TB in 2015 should
be less than 1 million.
By 2050: The global incidence of TB disease will be less than one per million population.
18
19
(WHO: http://www.who.int/tb/features_emergency_declaration/en/index.html)
WHO: The Global Plan to Stop TB 2006-2015, Actions for Life, 2006
9
Specifically, the new ten-year plan is intended to “achieve universal access to
scaled-up TB control.” The plan is based upon the “Stop TB Strategy.” It contains
the contents of Beyond DOTS as well as DOTS, i.e., is more wide ranging, premised
upon the fact that the conventional strategy focusing upon smear-positive TB control
has produced a steady effect but faces some problems.
The “Stop TB Strategy” has the following six components:
① Pursuing high-quality DOTS expansion and enhancement
② Addressing TB/HIV, MDR-TB, and other challenges (Refer to Section 2–2–2:
Multidrug-resistant TB control in Chapter 2.)
③
④
⑤
⑥
Contributing to health system strengthening
Engaging all care providers
Empowering people with TB, and communities
Enabling and promoting research
1 – 4: Major international organizations for TB control
The international community addresses TB control in global coordination.
The main three organizations are discussed below:
1 – 4 – 1: Stop TB Partnership
The Stop TB Partnership is composed of the WHO, IUATLD (refer to 1 – 4 –
2: International Union Against Tuberculosis and Lung Diseases), and national/private
aid organizations. It was founded in 1998 under the idea that these members would
stand up against the global crisis of TB in coordination among international
organizations and aid organizations instead of their separate cooperation activities.
The number of member organizations is over 400 as of 2005. (The Ministry of Health,
Labor and Welfare is a member of the Board representing the Japanese Government.)
The organizational structure of the Partnership is shown in Figure 1 – 4 below.
The core consists of the three bodies illustrated in the middle column. The WHO plays
an essential role in the Partnership in that it assumes the responsibility of working as its
secretariat. Nevertheless, it keeps its independence working under the initiatives of the
Global Drug Facility (GDF) and the Coordinating Board and is not an advisory
committee of the WHO.
Seven Working Groups (WGs) are formed to address the chief issues of today
(DOTS Expansion, Multidrug-resistant TB, TB/HIV, New TB Drugs, New TB
Diagnostics, New TB Vaccines, and Advocacy, Communication, and Social
10
Mobilization).
The WGs keep greater independence in their financing and
management than the three bodies. That is to say, each WG raises funds and initiates
its own projects. Each WG shares each country’s experiences, formulates standardized
guidelines, and develops new approaches, thereby steadily scaling up the strategies.
JICA renders cooperation to the Stop TB Partnership through attending WG meetings
for DOTS Expansion and TB/HIV, etc. together with the project experts dispatched to
each country as well as their counterparts.
Under the DOTS Expansion WG, there are sub-working groups: Laboratory
Strengthening, PPM, Childhood TB, and TB and Poverty. Each WG has been making
efforts to draw up guidelines in more detail.
Figure 1 – 4: Structure of the Stop TB Partnership
Source: The Global Plan to Stop TB 2006-2015 (WHO)
1 – 4 – 2: The International Union Against Tuberculosis and Lung Diseases
(IUATLD)
It was founded in 1920 and was renamed the IUATLD in 1989. It is a world
union organization constituted of private institutions (e.g., the Japan Anti-tuberculosis
Association from Japan). It is an organization to prevent and stop tuberculosis and
lung diseases particularly in low-income countries in the world. It has seven regional
offices in the world (in Africa, South Asia, Asia-Pacific, Europe, Central and South
America, the Middle East, and North America).
11
The World Conference on Lung Health of the IUATLD (or the IUATLD World
Conference for short) is held each year. This Conference is somewhat different from a
meeting of researchers/scholars. That is, the Conference is characterized by the feature
that a number of professionals in tuberculosis and other lung diseases come together not
only to present their papers and exchange opinions but also to look into the ways in
which various measures are implemented in each country and analyze problems. Since
professionals including researchers and public administrators of TB control from many
countries attend this IUATLD World Conference, the WG meeting of the Stop TB
Partnership is held a few days prior to the Conference.
In 2005, a joint meeting of three WGs (DOTS Expansion, TB/HIV, and
DOTS-plus) was held before the Conference.
Figure: 1 – 5: Organization Chart of the IUATLD
Source: http://www.iuatld.org/full_text/en/frameset/frameset.phtml
1 – 4 – 3: Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)
The Global Fund was created in 2000 as a private organization to give
assistance to fight AIDS, tuberculosis, and malaria. Its headquarters are located in
Geneva. Each round receives a proposal, to which funds are allocated.
It was established separately from the United Nations with the aim of dealing
with issues quickly by bypassing the gigantic bureaucratic organizations of the UN. A
Country Coordinating Mechanism (CCM) is separately formed for each country as a
12
system to process applications for grants and to implement and monitor the project. A
committee is established to represent the civil society of the country in question and
fulfills similar functions to those of a board of directors. The committee is constituted,
for instance, of the ministry of health, international organizations, and
non-governmental organizations including aid groups in the country in question.
Each round processes an application for a project. However, proposals
submitted by sub-recipients (governmental organizations, donors, and NGOs) that
implement the project are screened from a technical viewpoint by the Technical Review
Panel located in each country. As for accepted proposals, the principal recipient
(normally the ministry of health of the country in question, but an international
organization, for instance, in North Korea and Myanmar) submits an application to the
GFATM.
After being approved by the GFATM, the principal recipient and the GFATM
conclude a program grant agreement (PGM). The World Bank remits the fund to the
principal recipient, who then makes payment to the sub-recipient.
For the
implementation and management of the project, it is necessary to obtain authorization
from the Local Fund Agency (local supervisory organization). 20 The duration of a
project normally extends for a period of five years, but based upon evaluation of the
performance during the initial two years, its continuation is decided for the following
three years.
20
The principal recipient (PR) needs to submit an application for the remittance of the fund periodically as well as a
progress report and financial report, The Local Fund Agency confirms the relevance of the documents submitted
and recommends payment of the world fund according to the progress. When no progress is made under the project,
the secretariat requests remedial measures.
13
Chapter 2: Approach to tuberculosis
TB control has been implemented under DOTS or a strategic package. The
DOTS strategy is a measure based upon the perspective of public health and focuses
upon the detection and treatment of patients with smear-positive TB, which is the most
infectious form of TB, through public medical institutions. It has been proven that the
strategy is cost effective and also yields good treatment success. Hence, as discussed
under 1 – 3 – 4: DOTS Expansion and future prediction of TB in Chapter 1, it has been
adopted in 182 countries/regions out of 210 countries/regions in the world (as of 2004).
In recent years, the “Beyond DOTS” strategy, which is a package to be injected
as an additional input at a stage when treatment success and case detection rates have
risen to certain levels, has been developed and implemented depending upon the
progress and circumstances of each country.
The “Global Plan to Stop TB for 2006-2015” (discussed in 1 – 3 – 6: New
strategies from 2006) presents an explanation of “Beyond DOTS” as one package with
DOTS. It is believed that this interpretation will be more widely used in the future.
On the other hand, it should be noted that DOTS still remains the basis underlying TB
control and that this report is a reference material for JICA’s staff. Hence, in this paper,
DOTS and Beyond DOTS are separately explained to make the situation clear. The
relationship between DOTS and Beyond DOTS is equivalent to that of a tree trunk and
its branches. That is, only when the DOTS strategy has been sufficiently strengthened
can TB control be scaled up with selective Beyond DOTS measures.
2 – 1: Capacity development for DOTS implementation (Midterm goal 1)
2 – 1 – 1: What is DOTS?
DOTS is an acronym to indicate inclusive strategies of primary health services
implemented to detect and treat TB patients.
A patient who has been detected must be medicated every day for a period of
6~8 months. Even if the conditions of the patient have improved or the patient’s
complaints have vanished, he/she needs to keep taking strong drugs that may cause
harmful side effects. In order for the patient not to default from the course of
treatment, it is recommended that the patient takes drugs under the direct observation of
a medical professional for the initial two months as part of the DOTS strategy. Hence,
although depending upon the conditions of the disease and also considering the patient’s
14
accessibility to the clinic or adherence 21, a nurse or a midwife who has received proper
training carries out microscopy and medication confirmation at a peripheral medical
facility or a health center in a village, whereby every patient is able to receive
quality-assured treatment and bacteriology.
Figure 2 – 1: Conceptual diagram of the DOTS implementation system
＜
Roles
of
province/prefecture＞
the
Monitoring, evaluation,
supervision, treatment statistics,
and logistics such as drugs and
testing reagents
＜Roles of the county official in
charge of TB control＞
National TB program
To formulate guidelines and
training modules; monitoring,
evaluation, supervision, treatment
statistics, and logistics
management
Province/prefecture
＜Minimum unit of TB control＞
County official in
charge of TB control
Monitoring, evaluation,
supervision, treatment statistics,
and logistics such as drugs and
testing reagents
＜Roles of the health center＞
Health Center
Detection, treatment, recording,
and reporting of patients
DOT
TB patient
2 – 1 – 2: Components of DOTS
DOTS stands for “Directly Observed Treatment, Short-course.” It originally
meant a short-term chemical therapy carried out under direct supervision. The direct
observation of therapy (DOT) should be performed for at least the first two months.
Going beyond the treatment method, DOTS is now globally used to indicate a strategic
package for TB control consisting of five components, upon which the WHO lays
emphasis in TB control in developing countries.
21
The term is used to mean “medication observance.” The term “compliance” that has been used so far gives an
impression that a patient takes medication under the decision or direction of the medical service provider. On the
other hand, “adherence” connotes the patient’s will and attitude that he/she positively participates in the decision on
treatment policy and carries out and continues the treatment on his/her own accord.
15
DOTS is a strategic package composed of the following five pillars:
(1) Political commitment with increased and sustained financing
(2) Case detection through quality-assured bacteriology
(3) Standardized treatment, with supervision and patient support
(4) An effective drug supply and management system
(5) Monitoring and evaluation system and impact measurement
(1) Political commitment with increased and sustained financing
TB control must be carried out nationally and for a long period of time.
Hence, it
is essential to have a government’s active involvement to assure adequate funding and
competent human resources. DOTS is incorporated into the existing health care
system and implemented at peripheral levels in local areas under the command of the
central government.
(2) Case detection through quality-assured bacteriology
First, human and financial resources must be concentrated on the detection and
treatment of patients with sputum smear-positive TB that is the source of infection.
Sputum smear bacteriology with a microscope is performed at the general primary
medical level (the peripheral facility near residents) so that symptomatic patients can
have easy access.
(3) Standardized treatment, with supervision and patient support
Immediately after the beginning of the treatment, the patient discharges a lot of
bacilli (i.e., is highly infectious). Hence, what is critically required is to reduce the
risk of infecting other persons around the patient during the first two months’ treatment
(called the initial phase). For a period of at least these two months, it is of prime
importance to carry out standardized short-course chemotherapy under direct
supervision for a patient with sputum smear-positive TB.
(4) An effective drug supply and management system
A system should be built to ensure and maintain a stable supply of expendables
including quality-assured anti-tuberculosis drugs and diagnostic reagents so as not to
interrupt the treatment to TB patients.
(5) Monitoring and evaluation system, and impact measurement
16
Every detected patient must be registered, and the progress and results of his/her
treatment need to be monitored and analyzed based upon the result of sputum smear
microscopy. To that end, it is essential to develop a standardized TB registry and
reporting system.
17
2 – 1 – 3: Case detection and monitoring of treatment under DOTS
Patients are detected under DOTS in the procedure shown in the following
Figure 2 – 2.
Figure 2 – 2: TB diagnosis (sputum smear-positive pulmonary TB) under DOTS
Suspicion of pulmonary TB (person with
symptoms) (coughing for 2-3 weeks, sputum,
weight loss, chest pain, expectoration of blood,
hard breathing, etc.)
Sputum smear microscopy
(To color acid-fast bacilli by using the method of
Ziehl-Neelsen for microscopy)
Positive 1 time
Positive 2-3 times
Negative 3 times
Diagnosis by radiology and a
physician
Diagnosed as TB
Medication of non-targeted
antibiotics
Improved
symptoms
(non-TB case)
Symptoms do not
improve.
Retesting of sputum
Positive I time or more
Negative 3 times
Diagnosis by radiology and physician
Diagnosed as TB
To give treatment as sputum
smear-positive pulmonary TB
To give treatment as sputum
smear-positive pulmonary TB
※
Diagnosed as not TB
To consider other
possibilities
※ Smear-negative pulmonary tuberculosis means that sputum smear microscopy detects no
Mycobacterium tuberculosis but a person is diagnosed through his/her symptoms and radiography as
a TB patient by a physician. The case is classified under a different category from the case of
smear-positive pulmonary tuberculosis and is not included in the case detection and treatment success
rates to be achieved under the DOTS strategy.
18
Sputum smear microscopy is carried out at the following intervals during the
treatment to check whether it is bringing about a satisfactory effect, that is, whether it
has converted smear positive to smear negative (in case of the six-month short-course
regimen).
① At the end of the initial phase (initial intensive phase of treatment)
② Mid-point of the maintenance phase (in the fifth month)
③ Final month (the sixth month)
2 – 1 – 4: Characteristics of DOTS
The DOTS strategy is characterized by:
① A good command of patients through the TB registry system
A patient is detected through sputum smear microscopy, accurately recorded, and
reported regarding his/her treatment progress, thereby making sure that each patient
is provided proper treatment (i.e., to begin and complete the course of treatment and
confirm its result). It has been demonstrated that the tracing system, in which each
and every patient is picked up and followed through until his/her complete recovery,
eventually leads to measures to address the source of TB infection for the entire
community (public health activities).
② Detection of symptomatic patients primarily through sputum smear microscopy and
its treatment
Priority is given to the detection and treatment of patients with smear-positive
pulmonary tuberculosis that poses the most serious problem to public health (in that
Mycobacterium tuberculosis is discharged and infects other persons).
③ A package of a series of measures including case detection, supervision of
medication, supply of drugs, and sustainable management
The DOTS strategy does not merely mean that TB patients take their drugs in
front of a medical professional, that is, direct observation of therapy (DOT). A
decisive difference between DOTS and DOT lies in the fact that the WHO has
broadened the former’s definition to include a system to provide proper TB
treatment (whether quality-assured bacteriology is performed, whether
quality-assured drugs are properly distributed, and whether monitoring and
evaluation are appropriately carried out).
④ A package covering measures from prevention to treatment
The DOTS strategy contains the management of a patient including a series of
actions – prevention, bacteriology/diagnosis, and treatment. Furthermore, another
feature is that it is a comprehensive package integrating political commitment as
19
well.
⑤ Reasonable treatment cost per patient (US$10~30) with a high cure rate
⑥ Being based upon the numerical targets to be reached to stop TB
The DOTS strategy is grounded upon the model that enables the achievement of a
70% detection rate of patients infected with smear-positive TB, i.e., the most
contagious TB, and an 85% treatment success rate, thereby reducing the tuberculosis
incidence rate by 5~10% annually, or to put it another way, halving TB within 15
years (under the condition of no complications of HIV).
From the perspective of quality control, it is essential to carry out monitoring,
evaluation, and supervision 22 and assure the accuracy of sputum smear microscopy.
2 – 2: Capacity development for Beyond DOTS implementation for the vulnerable
population (Midterm goal 2)
A TB case detection rate of 70% has not yet been achieved globally. The
countries that have failed to reach the target are taking measures to expand and maintain
the quality of DOTS, which lies at the heart of TB control, to raise the treatment success
rate.
On the other hand, it has become obvious that further actions, or measures, so
to speak, beyond DOTS, are required to scale up TB control in addition to the basic
DOTS strategy.
For instance, it may be difficult to achieve the WHO’s targets in the rates of
case detection and treatment success when there are residents who have difficult access
to public medical services in developing countries due to problems in public health
administration or geographical/demographic factors. The DOTS strategy has shown
some limitations to varying degrees depending upon the extent to which the public
health and medical system is developed in the country in question. That is, after the
case detection rate has risen above 50%, it is not possible to reach 70% or more only
through the expansion of DOTS, which targets public medical facilities under the
leadership of public health administration. (The numerical figure of 50% is only an
experiential one calculated from past projects implemented by JICA. Thus, it is only
an approximate yardstick.) In addition, looming large are a couple of factors that are
detrimental to the treatment success rate as well as the case detection rate including the
spread of HIV infection and the emergence of drug-resistant strains of Mycobacterium
22
In some cases, the term is used to indicate “supervision by round.” However, in this context, it is used to include
the meaning of retraining for rectification or solution of problems found in the program by making use of the result of
assessment as well as through onsite supervision.
20
tuberculosis.
In order to solve these problems, a strategy called “Beyond DOTS” has been
proposed, which expands the scope of the DOTS strategy under the concept that is not
included in the basic DOTS strategy. The “Beyond DOTS” strategy covers a wider
range and contains the measures to be added to the basic DOTS strategy only when the
latter has been thoroughly implemented. Hence, it should be applied only after due
consideration of the necessity and possible effect according to the circumstances of each
country. It will be essential to bear this point in mind whenever it is introduced under
JICA’s cooperation project.
JICA will be able to render good-quality cooperation to Community DOTS,
urban DOTS, PPM, and collaborative TB/HIV (particularly in sub-Saharan Africa
where the HIV infection rate is high) in the light of its experiences, possible input
resources, and impact. On the other hand, JICA may find some difficulties in
extending technical cooperation to DOTS-plus (Refer to 2-2-2 (1)) and childhood
tuberculosis.
Figure 2 – 3: Relational illustration between DOTS and Beyond DOTS
Caused by measures
Caused by disease
Childhood tuberculosis
Multidrug-resistant
tuberculosis patients
Patients with difficult accessibility
to public medical facilities in
urban aress
Patients with difficult
accessibility to public medical
facilities in rural areas
TB/AIDS co-infected
patients
TB patients
TB patients
21
JICA’s policy is that provides cooperation primarily based upon the DOTS
strategy, but some measures of Beyond DOTS will be selectively added. This issue
will be discussed in Chapter 3 in greater depth.
Figure 2–3 illustrates a figurative tree that indicates the relationship between
TB patients and TB control. The leaves metaphorically express TB patients, whereas
DOTS is likened to the trunk for delivering necessary treatment services. In this
metaphor, Beyond DOTS that addresses the leaves placed in a special environment can
be likened to branches. In a country or region where the DOTS strategy, which is the
pivot of TB control and illustrated as the tree trunk, has not been yet established, new
components indicated as tree leaves should never be introduced. It is also
self-explanatory that the measures of Beyond DOTS, that is, large branches, cannot be
implemented under circumstances in which the trunk, or DOTS, is still fragile.
In some countries, there may be a marked regional disparity although DOTS
coverage is high nationwide. Hence, it is crucially important to confirm the main
indicators of TB control, assess the DOTS system, and place top priority on providing
necessary cooperation to DOTS before any measures from Beyond DOTS are
considered.
Note that the right-hand side of the illustration indicates cases in which
additional measures should be undertaken due to environment or other factors although
the disease is a normal TB, and the left-hand shows measures according to the types of
the diseases.
2 – 2 – 1: Measures of greater importance under Beyond DOTS
(1) Community DOTS
As discussed above, under the DOTS strategy, a medical professional directly
observes that a patient takes his/her drugs for at least 2 months subsequent to the
start of the treatment (in the initial phase). Patients normally take their drugs at the
medical facility. That is, they need to go to the facility every day. In local areas
of developing countries, particularly in rural areas, accessibility to medical services
is poor. Hence, it is difficult to motivate a TB patient to adhere to his/her treatment,
and the financial burden (transportation cost or loss of hourly wage) also makes it
more difficult for him/her to receive treatment regularly. As a result, these
countries are faced with the problem that there are many patients who fail to finish
(i.e., defaulters from) the course of TB treatment until they are fully recovered.
As a solution to these problems, DOTS watchers are trained (such as the
development of village health volunteers in the community), thereby enabling the
22
patient to receive DOTS services in his/her community. Thus, access to TB
control services is improved and the burden on patients is reduced. This principle
underlies the Community DOTS strategy.
Under this system, patients in rural areas receive support for medication
management through visiting medical services provided by medical professionals
from the health center, community health workers, or village health volunteers.
The Community DOTS strategy has been introduced in many developing countries.
In the background lie two significant factors: village health volunteers are now
placed in many countries, and NGOs have more abundant activity funds thanks to
the GFATM and other financing support, thereby making it easier to receive funds
for the payment of remuneration for health workers and the training of volunteers.
Due precautions should be taken so as not to destroy the existing services
given by the health center and to assure sustainability.
(2) Urban DOTS
Problems of urban tuberculosis in developing countries reflect the special
features of their urban problems: a high population density caused by an excessive
inflow of population (influx of refugees from other countries, influx of domestic
refugees, and inflow of the poor from local areas); the establishment and expansion
of poor settlements; extremely poor living environment; and a health and medical
service system that is unable to catch up with the increasing population. The
characteristics of TB in urban districts in developing countries can be summed up as
follows:
・A high rate of sputum smear-positive cases
・Outbreaks of TB from the socially weak
・Outbreaks of TB from foreigners and young adults
・Outbreaks of TB from floating populations and poor settlements
In cities, the incidence rate of sputum smear-positive TB is high, which is
responsible for the spread of infection, and an intensive density of population also
greatly raises the risk of infection. In cities, the inflow and outflow of people are
frequent as well, thereby making it very difficult to put TB patients under proper
control. Urban tuberculosis is typically characterized by the following: an
increasing rate of TB incidence caused by the influx of emigrants from a
TB-infected country, and growing cases of drug-resistant TB caused by a lowered
treatment success rate because people frequently change their abodes and the
23
homeless are on the increase.
The medical service system in urban districts heavily depends upon national
hospitals, private medical institutions, and pharmacies. This means that the
approach through health centers does not work effectively in many cases. It is
required to intensify the Hospital DOTS strategy, which is explained below.
As measures to deal with such problems, it is essential to strengthen public
leadership and build partnerships among public and private health and medical
service facilities, NGOs, and residents’ organizations. Another important factor
lies in the active participation in implementation. More specifically, it is
imperative to have coordination among a variety of organizations such as large
public hospitals, many private medical institutions including pharmacies, and
medical facilities in a special administrative district. For instance, in Kathmandu
of Nepal, as part of the urban DOTS system, JICA built a public-private partnership
in which the division of roles is demarcated between the health center and private
medical institutions. At the same time, JICA has supported system building
including a partnership with the medical system under the jurisdiction of the special
administrative district.
There are a number of defaulters from treatment in urban districts. What is
required is a system to follow up TB patients and encourage their return to treatment.
Under such circumstances, the present management system needs to be transformed
from service provider-centered TB control to patient-centered TB control. Human
resources, information, and facilities more heavily gravitate towards urban districts
in comparison to local areas. This means that there is greater availability of
medicines in cities. An effective way to carry out TB control in urban districts is to
make the maximum use of these advantages. Furthermore, it will also be effective
to aim at specific people or groups for TB prevention. Specifically, education and
explanation on TB are given to people who are highly susceptible to infection
(unemployed young people and people working in occupations with high risk) and
groups of people living in high-risk districts (poor settlements) or the whole district.
Education for these people will eventually reduce the number of defaulters and
enhance the early detection of TB patients.
＜Hospital DOTS＞
In urban districts, there are also many cases in which organizations such as
national hospitals are responsible for all TB control measures. Under Hospital
DOTS, the responsibility of such medical institutions is limited only to the process
24
up to case detection. The health center takes over the responsibility of treatment
that extends over a long period of time, because it is difficult for large hospitals to
make a follow-up of every patient. TB control under such a system is called
Hospital DOTS.
The main issues are to prevent hospital-associated infection and take
collaborative measures with referral medical institutions to ensure the follow-up of
each patient.
(3) Public-Private Mix (PPM)
[Also referred to as Public-Private Partnership (PPP)]
The Community DOTS strategy addresses TB problems in local areas. On the
other hand, in urban districts, there are also many cases in which proper DOTS
services cannot be delivered to patients under the basic DOTS strategy. That is,
TB control only through public medical facilities may fail to produce a good effect
in cities in particular, because private medical institutions and pharmacies that sell
anti-tuberculosis drugs often deliver TB services. The underlying reasons are
twofold. First, non-public medical institutions may lack sufficient knowledge,
thereby failing to give correct treatment. Second, TB control through public
medical facilities is unable to cover every case because a sufficient number of
health centers has not been established.
The PPM or PPP approach addresses these issues in order to step up TB control
in collaboration with private medical institutions in addition to public medical
facilities. In a number of cases, it is carried out in combination with Urban DOTS
and multidrug-resistant TB control (DOTS-plus). In the Philippines, for instance,
in local areas where people often use private medical institutions or in urban
districts where people use private medical institutions with great frequency, there is
great need to incorporate private medical institutions into TB control.
Besides PPM, there is an approach in which public medical institutions do not
charge for their TB treatment care service and anti-TB drugs in order to increase the
competitiveness of public institutions.
(4) TB/HIV (TB/HIV co-infection)
Collaborative TB/HIV control is required from the standpoints of both TB
control and HIV control. To put it simply, an increment in the number of
HIV-infected persons has induced an upsurge in the number of TB patients and at
the same time, in the number of deaths. TB is basically a curable disease with
25
affordable treatment. The same can be said of tuberculosis among HIV carriers as
long as it is detected at an early stage. HIV control also will benefit greatly from
building a system under which TB patients who have completed TB treatment will
be able to receive proper medical treatment for AIDS.
In fact, there are a number of deaths in the middle of treatment because a patient
comes to a health center at a later stage and because HIV infection accelerates the
progress of TB conditions. The biggest challenge, from the viewpoint of the HIV
service provider, is that TB is the most opportunistic infection and brings about a
number of deaths despite the fact that it is a curable disease.
1) The world situation
Approximately one third (13 million persons) out of the total number of
HIV-infected persons (about 40 million persons) are also infected with TB. 23 In
sub-Saharan Africa, TB was on the decrease until the mid-1980s. However, in
2005,
the number of TB patients approximately quadrupled. 24 Increases in
population and improvements in TB case detection also contribute to this increment,
but it is believed that HIV infection is a major factor. For example, in Zambia, the
national rate of HIV infection is 17% 25, whereas 76% of TB patients are diagnosed
as HIV positive at the JICA project site. 26 It is reported that in urban districts,
about 83.2% of TB patients are infected with HIV. 27 The registered number of TB
patients was approximately 100 per 100,000 persons in the 1980s. The number
continued to rise and exceeded 500 in 2002. 28 According to the HIV infection
surveys carried out in 2002 and 2004 in Cambodia where the HIV infection rate was
only 1%, the percentage of TB patients infected with HIV was 10% and 8%,
respectively (JICA Cambodia TB Control Project Report, 2003). These findings in
Zambia and Cambodia imply that a factor contributing to the increased number of
TB patients is HIV infection. The situation plotted on the world map indicates that
countries with high TB incidence rates and countries with high HIV infection rates
nearly overlap. In particular, it is important to note that tuberculosis is a serious
problem when HIV/AIDS control measures are considered for sub-Saharan Africa.
Figure 2 – 4: Estimated TB/AIDS co-infection rate – WHO (2005)
23
WHO TB Department, fact sheet on tuberculosis
http://www.who.int/hiv/toics/tb/tuberculosios/en/
25
2006 Report on the global AIDFS epidemic: UNAIDS
26
Mizutani, Tetsuo, et al.: HIV/AIDS in Sub-Saharan Africa, with focus on the Republic of Zambia, VIRUS
REPORT, Vol. 3, No. 1, 2006
27
Epidemiological Fact Sheet: WHO/UNAIDS, August 2006
28
WHO TB Epidemiological Profile as of May 31, 2005
24
26
HIV prevalence in
TB cases, 15-49 years
(%)
0－4
5－19
20－49
50or more
No estimate
Areas where TB infection spreads with
the prevalence of HIV
Source: WHO Report 2007: Global TB Control Surveillance, Planning, Financing
Figure 2 – 5: Progress of HIV infection
Infection with HIV
Progress of HIV infection
CD4-Positive lymphocyte counting
window
period
Virus
Primary
infection
stage
(acute
infection)
Asymptomatic stage
Late stage – HIV
disease (AIDS)
Herpes zoster
Tuberculosis
Kaposi’s sarcoma
Pneumocystis carinil pneumonia
Candidiasis (esophagus, etc.)
Possible to have
symptoms when CD4
counting is less than
200
Cryptococcus meningitis
Cerebral toxoplasmosis
Cytomegalovirus retinitis/pneumonia
Atypical mycobacteriosis
Malignant lymphoma
HIV-associated
dementia
Note: CD4, or cluster of differentiation 4, count: CD4 is one type of lymphocyte that
fulfills the central role of immune function. It is used to confirm the conditions of
an HIV carrier’s immunity. After infection, the count goes down gradually.
When it goes below 200, the carrier can be attacked by opportunistic infections.
TB is one of the most contagious diseases and can infect even healthy persons.
27
Hence, a person who has a CD4 count of 500 can contract TB. This means that an
HIV-infected person is most susceptible to TB infection and disease, whereby TB is
the leading cause of death among HIV-infected persons.
Source: Anti-HIV therapy and medication support (AIDS Clinical Center,
International Medical Center of Japan)
2) TB/HIV control
It is believed that collaboration between TB control and AIDS control will yield
positive effects for both control measures. Under the Stop TB Initiative, activities
are carried out with the main focus upon the following issues: 29
Establish the mechanism for collaboration
(1) Set up a coordinating body
(2) Conduct surveillance of HIV prevalence among TB patients
(3) Carry out joint TB/HIV planning
(4) Conduct monitoring and evaluation
1. Decrease the burden of tuberculosis in people living with HIV/AID
(1) Establish intensified tuberculosis-finding
(2) Introduce isoniazid preventive therapy
(3) Ensure tuberculosis infection control in health care and congregate settings
2. Decrease the burden of HIV in tuberculosis patients
(1) Provide HIV testing and counseling
(2) Introduce HIV prevention method
(3) Introduce cotrimoxazole preventive therapy
(4) Ensure HIV/AIDS care and support
(5) Introduce anti-retroviral therapy (ART)
In response to the full-scale introduction of anti-retroviral therapy, the Joint
United National Programme on HIV/AIDS (UNAIDS) and the WHO announced
their view in June 2004 that HIV antibody testing for TB patients would form a part
of standard treatment. At the same time, the UNAIDS/WHO Joint Policy
29
Interim Policy on Collaborative TB/HIV Activities, WHO/HTN/TB/2004.330
28
Statement 30, the Guidelines for HIV Surveillance 31, A guide to Monitoring 32, and the
Clinical Manual 33 were published or revised. In the call for proposals by the
GFATM in March 2005, it was decided that one of the requirements for funding was
to incorporate the TB component into AIDS control and the AIDS component into
TB control. 34 Thus, it is an inevitable trend to integrate the TB/HIV components in
cooperation either for AIDS control or for TB control. The above components of
TB/AIDS control are based upon the experiences gathered from the pilot projects
implemented in six countries including Malawi, South Africa, and Zambia.
Currently, TB/HIV control has been implemented in Ethiopia, Kenya, Malawi,
Mozambique, Nigeria, South Arica, Uganda, Tanzania, Zambia Zimbabwe, Republic
of Cote d’Ivoire, the Democratic Republic of the Congo, Rwanda, and Senegal.
One challenge faced by TB/HIV control is that collaboration has not progressed
as expected. TB is an opportunistic infection that infects other persons, thereby
posing a menace to HIV-infected persons. As discussed above, the TB incidence
rate is extremely high among HIV carriers. That is, even though the HIV infection
rate is 1% nationwide, the number of TB patients may double per year. Thus,
tuberculosis cannot be dealt with merely as an opportunistic disease among
HIV-positive persons. It is reported that AIDS control administration often lacks
this awareness, which poses a serious problem. On top of this, TB control has a
long history. As a result, it has established an approach that is refined to a high
level. At the same time, it is not a project that attracts a lot of attention. On the
other hand, HIV/AIDS control is a new project in which a massive amount of funds
are injected, many actors are involved, and multisectoral activities are mainstreamed.
Thus, there are differences in the persons involved, history, and approach to
activities. Such dissimilarities are reflected in the present situation.
2 – 2 – 2: Others
(1) Multidrug-resistant tuberculosis control (DOTS-plus) 35
A form of tuberculosis caused by strains of Mycobacterium tuberculosis against
which multiple drugs do not work is called multidrug-resistant tuberculosis (MDR-TB,
30
(UNAIDS/WHO Policy statement on HIV testing, June 2004)
Guidelines for HIV surveillance among tuberculosis patients (second edition): WHO/HTM/TB/2004.339
32
A guide to monitoring and evaluation for collaborative TB/HIV activities: WHO/HTM/TB/2004.342
33
TB/HIV Clinical Manual: WHO/HTM/TB/2004.329
34
The Global Fund to Fight AIDS, Tuberculosis and Malaria: Guidelines for proposals: Fifth call for proposals.
Geneva, March 17, 2005
35
XDR-TB: In the past, multidrug resistance was defined as a bacterium that shows resistance to two types of
anti-tuberculosis drugs. Today’s new findings reveal that there is a form of tuberculosis that has resistance to three
types of drugs in the second line (including six types in total) called XDR-TB. This tuberculosis begins to pose a
problem in that there is no treatment that meets the global standards.
31
29
or Mycobacterium tuberculosis, that shows resistance to at least rifampicin and
isoniazid). Multidrug-resistant tuberculosis has the following causes:
1) Interruption of the patient’s treatment
2) Wrong prescription by physicians
3) Inferior-quality drugs
The TB control strategy including measures to control multidrug-resistant tuberculosis
is called DOTS-plus.
The DOTS-plus strategy includes standardized procedures in addition to the
contents of the DOTS strategy; drug sensitivity testing to confirm multidrug-resistant
tuberculosis; procurement of special drugs; standard precautions to prevent
hospital-associated infection to other patients; and surgical operation.
Mycobacterium tuberculosis sometimes undergoes gene mutation into a strain
of drug-resistant bacterium although such mutations do not occur as frequently as they
do in the influenza virus. 36 Under the DOTS strategy, medication is so designed as to
be able to cure tuberculosis. That is, four types of anti-tuberculosis drugs are
administered in combination so that TB can be cured even if the bacterium undergoes
gene mutation into a strain resistant to one type of drug.
In the case of multidrug-resistant tuberculosis, the anti-tuberculosis drugs that
are normally used (first-choice drugs or first-line drugs) do not work. Therefore,
second-line anti-tuberculosis drugs are used. If these drugs have no efficacy, the form
of tuberculosis against which no drugs work may spread extensively. Therefore, it is
vital to supervise medication under direct observation more strictly than when treating
normal types of tuberculosis so that no patients default from treatment. Surgical
removal is opted for in some cases. In Japan, it is recommended to have treatment at
hospital. In this case, it is critically necessary to strengthen the measures to prevent
hospital-associated infection so that medical staff and other patients do not become
infected.
Treatment for this multidrug-resistant tuberculosis involves a few difficulties:
first-line drugs cost US$10~30 per person, whereas the cost of second-line drugs jumps
to about US$3,000; the duration of treatment extends over a period of 18 months or
more (the normal duration being 6~8 months); and the treatment success rate drops to
less than half . 37
36
In general, there is one inherently (naturally) resistant bacterium per one million bacilli of Mycobacterium
tuberculosis to one drug. It is calculated that there is about one inherently resistant bacterium per one trillion
bacteria (one million x one million) that is resistant to two drugs when two drugs are taken. It is believed that there
are about from 10 million to one billion bacilli per lesion in the lung. Thus, it is possible to avoid an increase in the
number of resistant bacteria by taking at least two drugs.
37
“Drug- and multidrug-resistant tuberculosis (MDR-TB) – Frequently asked questions”
30
There is a global framework to address multidrug-resistant tuberculosis that
often involves difficult issues in its control. It is the Green Light Committee within the
Stop TB Partnership. It has been founded because technical and financial difficulties
surround multidrug-resistant tuberculosis and failure to control it may result in the
spread of a form of tuberculosis for which no treatment technology has yet been
developed. Once the Committee approves the proposal submitted by a nation infected
with multidrug-resistant tuberculosis, the country is able to receive technical and
financial support (including the supply of second-line anti-tuberculosis drugs).
JICA will recommend that such countries receive support from the Green Light
Committee. Likewise, JICA extends cooperation emphasizing the prevention of
multidrug-resistant TB, contributing toward raising case detection rate while
maintaining a high treatment success rate.
(2) Childhood tuberculosis
Necessary measures should be taken against childhood tuberculosis in
countries where tuberculosis is prevalent. It is difficult to take sputum from small
children, thus the detection of tuberculosis among babies with sputum microscopy,
which is one of the DOTS’s basic strategies. Hence, a special program (diagnosis with
radiography, etc.) needs to be offered to small children. There is a high probability
that childhood TB cases are excluded from the statistics because they cannot be easily
detected by sputum microscopy. A first glance may give the impression that the
burden of childhood tuberculosis is relatively small. It is essential to be aware of this
fact when measures are considered.
One possible measure may be contact examination. When a sputum
smear-positive patient is detected, the contact examination should be given,to his/her
family members, thereby efficiently finding a patient with childhood tuberculosis.
Persons near the patient are at the highest risk of being infected and a number of
infection cases take place within the family, i.e., of those who keep in close contact with
the patient. Thus, contact examination is effective for finding cases. The contact
examination given to persons near sputum smear-positive patients carries great
significance for high-TB-prevalence countries or regions. Indeed, in some countries,
contact examinations are given to small children aged five or less.
In advanced countries including Japan, the contact examination is conducted to
detect a TB-infected person at an early stage, that is, before the onset of tuberculosis to
stop its development into a full-blown disease with preventive medications. However,
http://www.who.int/tb/dots/dotsplus/faq/en/index.html
31
the examination is hardly carried out in developing countries.
The infection source of childhood tuberculosis is, in many cases, a family
member who has not completed his/her treatment, and there is a relatively high
possibility that a child is infected with drug-resistant tuberculosis. Hence, it is
essential to keep this point in mind.
2 – 3: To summarize JICA’s past cooperation
JICA has extended its aid for TB control in many countries by integrating
various schemes such as project-type technical cooperation, training program, and grant
aid in close partnership with international organizations and related aid organizations.
Since 1995, JICA has been implementing its cooperation projects primarily in
accordance with the DOTS strategy that is the global standard.
Among countries where JICA has rendered cooperation, program-type
technical cooperation markedly stands out in countries where JICA has implemented
project-type technical cooperation. To put it specifically, by using various schemes,
JICA has provided assistance for capacity development, thereby enhancing human
resource development, system building, and institution building. Basically, the
project aims to improve the national tuberculosis program (NTP) so that the government
of the recipient country will develop the capacity to carry out the DOTS strategy on its
own.
＜Features of JICA’s past cooperation＞
1. Aid to introduce DOTS and improve its quality (since 1995)
2. Capacity development focusing upon human resource development for TB control
program nationwide, thereby strengthening the management capacity of the national
tuberculosis control program
3. Introduction of the DOTS strategy, which is the global standard, in a form
applicable for each country
4. Program-type approach by integrating various schemes
5. Human resource development in as many countries as possible through the training
program in Japan
It has been proven that the DOTS strategy steadily brings about success in the
patient’s treatment in many countries. Against this backdrop lies a reason that the
DOTS strategy has not grown in answer to the question: “What comprehensive services
32
should be provided?” Instead, it has come in answer to the question: “What could be
done in developing countries where human resources and systems are limited?”
Whenever JICA formulates a project, JICA has modified the DOTS strategy
discretionally into a form applicable to the country in question. Specifically, JICA
implements a model/pilot project and builds a DOTS model suited to the country in
question. Then, JICA implements the model project nationally through the training of
health workers who are in direct contact with residents.
(1) Development of DOTS suited to the health and medical system of each country
1) To review and evaluate preexisting TB control measures
a) To formulate drafts of guidelines and training modules
①
Management of patients (detection, medication, and record
keeping/reporting )
② Sputum smear microscopy
③ Logistics concerning anti-tuberculosis drugs and testing reagents etc.
④ Monitoring, evaluation, and supervision concerning ①~③ at the model site
b) To revise and formalize the guidelines and training modules (drafts)
(2) To give training to the health staff who keep direct contact with residents to
introduce DOTS
(3) Training on monitoring, evaluation, and supervision to administrative officials in
charge of tuberculosis control in the provincial, prefectural, and national
governments
JICA’s training course in Japan has a history of over 40 years and has
developed human resources who play the pivotal role in TB control and also assume
responsibility in the laboratory in each country. The number of persons trained on this
training course has reached approximately 1,500. In addition, JICA has rendered
cooperation that organically links those participants with JICA’s projects.
33
Figure 2 – 6: JICA’s cooperation for TB control by project-type technical cooperation
(As of January 2005)
Project-type technical cooperation as of April 2007
TB Control Project in
Afghanistan
TB Control
Project in
Pakistan
Community
Tuberculosis and
Lung Health Project
(Phase 3) in Nepal
TB Control Project
(Phase 3) in Yemen
Public Health Project
in the Solomon Islands
TB Control
Improvement
Project (Phase 3)
in the Philippines
AIDS/TB Control Project in
Zambia
Project under way
Project under
preparation
Project for
Infectious Diseases
Control in Myanmar
TB Control Project in the
TB Control
Project in
Indonesia
Kingdom of Cambodia
(Phase 2)
Completed project
2 – 3 – 1: Technical cooperation
JICA rendered cooperation to the Solomon Islands, Yemen, and Nepal, which
produced a good outcome. Currently, JICA is implementing projects in the Philippines,
Cambodia, Myanmar, Afghanistan, Pakistan, and Zambia. It plans to begin a project in
Indonesia in the near future. (Please refer to Appendix 1 – Major examples of
cooperation.)
2 – 3 – 2: Cooperation through training, etc.
The training course in the area of tuberculosis held in Japan was started in 1963
as “Tuberculosis Control.” It was a four-month course held in partnership with the
Japan Anti-tuberculosis Association for medical personnel, primarily physicians, who
were involved in TB control. In total, 552 persons participated in the course from 58
countries during the period until 1992.
One outstanding feature of this training course is that it has contributed to the
development of human resources in a number of countries for a long period of time.
There is the case in which a project is implemented in a given country in combination
34
with an in-country training course. A fruit of JICA’s project-type technical cooperation
is that it is now possible to hold a training course in the laboratory sector in the
Philippines. Hence, since fiscal 2006, the training of trainers (TOT) course has been
held in the said country.
Furthermore, JICA has been conducting training by making effective use of the
local resources of developing countries of late. For instance, JICA supports the
training of counterparts of a project for Cambodia at a heart hospital in Thailand (built
with grant aid and project-type technical cooperation). Thus, JICA now makes active
use of third-country resources.
When the cooperation policy is reviewed in the future, it will be essential to
clearly delineate the distinct roles of human resource development, system building, and
institution-building that are carried out under the overall goal of capacity development
(3 – 3 – 2: Development and strengthening of input resources in Chapter 3).
2 – 3 – 3: Application of a modified DOTS strategy for each country
In the past, guidelines for public health were often formulated from the
perspective of what should be done in developing countries. One of the reasons that
DOTS has been successfully adopted and produced a good outcome throughout the
world is its simplification so that it can be operated in developing countries with limited
resources. Specifically, for instance, it can be seen in a simplified laboratory register
form (global standard) and patients’ register form, and monitoring and supervision
based on the both forms.
Nevertheless, the capacity level of the staff, the number and quality of medical
facilities, and the conditions of diseases excluding tuberculosis vary in each country.
Hence, there is no universally applicable operational approach to the DOTS strategy.
The key to success in TB control is to discover the optimum form of feasible DOTS and
create DOTS guidelines to meet the conditions of each country. The projects
implemented by JICA in the past are characterized by the feature that JICA has followed
a process consisting of a series of formulating guidelines verifying the feasibility at a
model site and feedback to the TB policy, which is the process of operational
researches.,.
2 – 3 – 4: Grant aid
Grant aid to the area of tuberculosis has been effectively used in combination
with project-type technical cooperation. The aid can be roughly divided into two
types: the facility type in which a tuberculosis center or a central tuberculosis laboratory
35
is constructed, and the equipment/reagent type in which national tuberculosis control is
intensified by supplying anti-tuberculosis drugs and microscopes.
The tuberculosis center contributes to functional strengthening of control
measures including co-infection and multidrug-resistant tuberculosis as the central
control center. Similarly, the tuberculosis laboratory fulfills the role of the national
reference laboratory with its strengthened functions of training and external quality
assurance.
2 – 3 – 5: Collaboration with volunteer projects
Aid to the area of tuberculosis under volunteer program has primarily consisted
of the dispatch of health nurses to ensure the enforcement of DOTS at hospitals and
health centers. Specific cases are summarized in Appendix 1 “Table A1 – 3: Dispatch
of JOCV members to strengthen TB control.”
There are many cases of cooperation by volunteers to improve public health
systems, as can typically be seen in the dispatch of members for the eradication of
smallpox and polio and the strategic dispatch of members, for instance, for anti-AIDS
actions. In the future, there is a possibility that JICA will strategically dispatch
volunteers in the area of medicine including public health nurses, clinical laboratory
technicians, and radiologists, strengthening the national TB program. At the same
time, JICA can look toward the possibility of dispatching people from the liberal arts,
not from the area of medicine, who wish to participate in volunteer program as has been
done in the area of HIV/AIDS.
2 – 4: Human security and tuberculosis 38
Tuberculosis and human security are closely related in the following two
aspects: first, tuberculosis poses a direct threat to each individual in terms of health and
survival that are basic human needs; second, the burden of tuberculosis is concentrated
on the poor and vulnerable, thereby further deteriorating their frailty. These two
aspects interfere with “freedom from fear” and “freedom from want” that are integral to
human security.
Not limited to tuberculosis, disease control measures and health/medical
improvements eventually contribute to human security. Tuberculosis is a disease that
can be detected with a relatively simple method and cured with affordable drugs. In
addition, its complete treatment reduces the risk of infecting other persons surrounding
38
Japan International Cooperation Agency: The Republic of Ghana. Final evaluation report of the Infectious
Diseases Control Project for the Noguchi Memorial Institute for Medical Research: September 2003
36
the patient, and the DOTS strategy, which evidently yields a good outcome, has been
established. Thus, assistance for TB control under the DOTS strategy is a significant
effort from the perspective of human security.
The following sections discuss TB control viewed from human security.
(1) DOTS and human security
The DOTS strategy makes it possible to detect TB-infected persons, ensure that
they are treated, and lower the risk of infecting others through the complete cure of
patients, whereby it enables the prevention of infection of an entire community. In
Japan, discrimination and prejudice against TB patients and tuberculosis have been
removed due to the progress of TB treatment. 39 In this sense, it may be stated that
the DOTS strategy is an approach that translates the idea of human security into
action. Further, it raises the entire level of the basic health and medical system that
provides services to local residents. Hence, the approach may be applied to control
measures for other diseases. As one example, the DOTS strategy may be
applicable to AIDS treatment (anti-retroviral treatment - ART) that requires
medication over a longer period of time than tuberculosis. The cycle of DOTS is
relevant to the three phases of risk management: “prevention,” “action,” and
“promotion.” 40 That is, each phase is respectively addressed by strategies under
DOTS: “halting the spread of TB through treatment,” “treatment,” and
“development of a health system.”
(2) TB control for the poor
Tuberculosis is tightly associated with poverty as clearly indicated by the fact that it
is referred to as a “disease of poverty” (Figure 2 – 7). Over 95% of TB-infected
persons and TB deaths are concentrated in the developing world, and mostly the
poor fall victim. People in poverty are often faced with a wide range of problems
including nutritional conditions, density of housing (poor settlements and illegal
settlements in urban districts, etc.), and work environment, thereby multiplying the
risk of TB infection and worsening TB conditions.
In fact, it has been reported that the risk factor is 2.5 times higher among the
poor than the non-poor and also that the TB prevalence rate is 1.6 times higher
among the poor in urban districts than the non-poor in the Philippines (WHO
39
Shimao, Tadao: “Thoughts about future AIDS control measures learned from TB control”: Journal of AIDS
Research 3: 45-49, 2001
40
Institute for International Cooperation, JICA: “Poverty reduction and human security – Discussion paper”:
November 2005
37
Regional Office for the Western Pacific). 41 It is reported on China that 78% of TB
patients belong to social strata that earn lower than the average income.
Tuberculosis is concentrated among the poor. Hence, strengthening of TB
control leads to poverty alleviation. The DOTS strategy basically places priority
on delivering TB services through public health/medical institutions. However,
there are some cases in which the poor are unable to receive such services. If that
is the case, it will be necessary to adopt additional measures besides DOTS.
Specific examples include free treatment, free food supply to TB patients under the
Food-for-Cure by the World Food Programme, urban tuberculosis control, PPM
(PPP), and community DOTS.
Figure 2 – 7: Poverty and TB infection risk
Poverty
Lowered nutritional condition
Worsened
disease conditions
Poor and dense work environment
Increase in TB
infection risk
TB infection
Increase in the number of
TB-infected persons
Worsened poverty/death
Infection to family members
Deepened poverty
(3) Refugees and tuberculosis
Refugees from war or civil war are confronted with diverse problems including
housing, food, and health problems. Tuberculosis is one of them. There are too
41
“Reaching the poor: challenges for the TB programmes in the Western Pacific Region”: WHO Regional Office for
the Western Pacific, 2004. 33 pages, ISBN929061093X
38
many problems surrounding refugees. Hence, the problem of tuberculosis has been
neglected. In fact, 25% of adults die of tuberculosis in refugee camps in Somalia.
The death of an adult inflicts an adverse effect on his/her family, especially the
children, thereby aggravating problems. The poor environment of refugee camps,
much worse than that of poor settlements, magnifies the damage caused by
tuberculosis. The fact that a TB patient must undergo the 6~8-month course
regimen also creates difficulties. Thus, the TB problem indeed looms large in
refugee camps. 42
2 – 5: Gender and tuberculosis
Tuberculosis poses a menace to women. That is, more women die of
tuberculosis than of delivery each year (World Bank 1993). On the other hand, TB
infection rates are higher in men than in women. However, the risk of being infected
with TB and developing the full-blown disease is 2.3 times higher among women in
their 20s~40s than their male counterparts. Similarly, the conditions of the disease
are worse among women at the time of diagnosis. 43
These problems stem from an inferior environment surrounding women in
developing countries, family care being in women’s hands in many cases and difficulty
of accessibility to external services including medicines. A glance at the ratio of men
to women in some countries reveals that the proportion of women under treatment is
lower than the percentage of projected TB-infected women compared with that of men.
This evidently demonstrates an unequal situation of women.
In recent years, various committees have been established to look into the
relationships between gender and tuberculosis. JICA needs to collect information
continuously on this issue and reflect the result accurately in its technical cooperation. 45
42
“A human rights approach to TB. Stop TB Guidelines for Social Mobilization” WHO/CDS/STB/2001.9
“A human rights approach to TB. Stop TB Guidelines for Social Mobilization” WHO/CDS/STB/2001.9
45
Tuberculosis and gender (http://www.who.int/tb/dots/gender/page_l/en.index.html)
43
39
Chapter 3: JICA’s cooperation policy on TB control
This chapter discusses JICA’s cooperation policy and approach, and then looks
into challenges in TB control.
3 – 1: JICA’s cooperation policy on TB control
JICA gives priority to the countries in which tuberculosis brings about a heavy
burden and TB control lags behind. It is JICA’s policy to extend its assistance to those
priority countries with an emphasis on improving the quality of DOTS and expanding
the operation of Beyond DOTS. JICA carries out a careful analysis of the country in
question in terms of the implementation system in place, the country-specific
cooperation plan and the significance of infectious disease control in the cooperation
program for the health sector. In light of all these factors, JICA formulates a
cooperation program.
A general cooperation policy is that JICA extends assistance to the countries
that meet the condition of 1. in the following list, stressing the cooperation of either 2.
or 3., or in a combination of components from 2. and 3. For other countries that do not
fall in the category 1., JICAs cooperation will not solely focus on TB control, but TB
control could be included in a project for other infectious diseases (e.g. HIV/AIDS), or a
project for strengthening rural health care. JICA will extend assistance towards capacity
development in general for persons involved in TB control such as acceptance of
participants in the group course held in Japan.
＜JICA’s cooperation policy on TB control＞
1. Give priority to High-Burden countries, high-TB-incidence countries, and
countries where TB control lags behind
2. Place an emphasis on strengthening the quality of DOTS
3. Improve the capacity to implement Beyond DOTS for the vulnerable population
3 – 1 – 1: Give priority to High-Burden countries
Countries where the burden of tuberculosis is serious and TB control lags
behind are selected as the priority countries of JICA’s cooperation. The TB burden in a
given country is measured by two aspects: first, a country where there are many TB
patients (high-burden country) and, second, a country where the TB incidence rate is
40
high. Table 3 – 1 lists countries with a high number of TB patients 44 and countries with
high TB incidence rates 45 in a descending order, respectively.
These indicators show merely the static condition, but it is necessary to grasp
the dynamic condition of how measures are taken to intensify TB control by analyzing
changes in the past several years.
Table 3 – 1: High-burden countries and high prevalence rates
Name of country
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
44
45
India
China
Indonesia
Nigeria
Bangladesh
Pakistan
South Africa
Ethiopia
Philippines
Kenya
Democratic Republic of Congo
Tanzania
Uganda
Mozambique
Myanmar
Zimbabwe
Cambodia
Afghanistan
Swaziland
Djibouti
Namibia
Lesotho
Botswana
Zambia
East Timor
Sierra Leone
Malawi
Ivory Coast
Togo
Congo
Rwanda
Order of
High-burden
country
1
2
3
4
5
6
7
8
9
10
11
14
16
18
19
20
21
22
Number of TB
patients
1,851,661
1,319,328
532,871
371,642
321,996
286,291
284,538
266.288
241,879
219,582
204.977
131.078
106,285
88,533
88,345
78,187
71,130
50,249
13,029
6,045
14,164
12,489
11,551
70,026
5,261
26,266
52,751
69,417
22,910
14,659
32,627
Order of
prevalence
rate
62
80
40
32
45
53
8
22
31
6
21
23
18
13
60
7
11
61
1
2
5
4
5
9
10
12
14
15
17
19
20
“Countries with high number of TB patients ”: Estimated number of patients per year (incidence)
“Countries with high proportion of TB patients ”: Total TB incidence rate
41
Prevalence rate
(per 100,000)
168
100
239
283
227
181
600
344
291
641
356
342
369
447
171
601
506
168
1,262
762
697
696
654
600
556
475
409
382
373
367
361
32
33
34
Burundi
Central Africa
Haiti
25,188
12,670
26,051
24
25
27
334
314
305
Infectious Disease Control Team, Human Development Department, JICA (June 11, 2007)
Reference: WHO Report 2007: Global TB Control Surveillance, Planning, Financing
1. Priority countries of cooperation for TB control
(1) High-burden countries (with many TB patients): 22 high-burden countries
(2) High TB incidence rate (a high proportion of TB patients)
・Countries with high HIV incidence rates
・Post-conflict countries
(3) Countries in which the DOTS strategy lags behind
・Countries in which the case detection rate and the treatment success rate have not
improved for the past 2~3 years
(1) High-burden countries (22 high-burden countries: in terms of the estimated number
of TB cases)
As explained in Chapter 1, over 80% of 9 million TB patients in the world are
concentrated in the 22 high-burden countries. JICA will extend cooperation to
these countries with the highest priority.
In the past several years (as of 2005), an increasing number of new TB patients
were detected in parallel with the expansion of HIV infection. Hence, there are
some changes in the ranking around the 22nd high-burden country. As of 2005,
WHO was looking into the possibility of increasing the number of high-burden
countries from 22 to 30. In fact, the WHO annual report of 2005 left out a map of
high-burden countries (HBCs).
As for countries other than the 22 countries, JICA is ready to review the
priority countries, if required, depending upon the number of patients or incidence
rate proportionate to those of the present priority countries, as will be discussed in
the following section.
(2) Countries with high TB incidence rates [Table 3 – 2 (right-hand side)]
The fact that a country has a high TB incidence rate means that there is a high
risk of a further increase in the number of TB patients in the country. It means,
therefore, priority should be given to TB control.
Among countries with high TB incidence, there are two types as can be
obviously seen from Tables 3 – 1 and 3 – 2: ① countries with many HIV-infected
42
persons and ② countries after the end of civil war. The cooperation extended to
each type of such countries is different in terms of its approach and content. An
explanation is given in more detail in “3 – 3 – 1.”
※About trends in the TB case detection rate and treatment success rate
Viet Nam and Thailand are still counted as high-burden countries (HBCs), but
cited as successful cases just as is Peru, which is no longer listed as an HBC. This
is primarily because of marked progress in TB control measures undertaken by the
the respectiev government. These two countries are, therefore, excluded from Figure
3 – 1. The exclusion is based upon the assumption that the governments of these
countries succeed in strengthening TB control and that there is no longer high
necessity for JICA to support the DOTS strategy, which is at the core of TB control,
and the Beyond DOTS strategy.
The progress of TB control can be measured from the trends in the number of
TB patients and TB incidence rates as shown in Figure 3 – 3.
(3) Countries where the DOTS strategy lags behind
The progress of TB control is assessed from the rate of patients who are
detected under DOTS (DOTS case detection rate) and the rate of patients who have
completed treatment out of those detected patients (treatment success rate). The
extent to which the DOTS strategy has been intensified can be measured by changes
in the case detection rates under DOTS and the treatment success rates in the past
2~3 years.
Please refer to Figure 3 – 4 as for the performance of JICA’s cooperation in the
aid priority countries of TB control.
43
Table 3 – 2: Comparison of ranking by the estimated number of TB patients and estimated TB incidence rates
(2005)
Ranking of the estimated number of TB patients*
Ratio
(100,000)
1,851,661
1,319,326
532,871
371,642
321,996
286,291
284,538
266,288
241,879
219,582
204,977
168
100
239
283
227
181
600
344
291
641
356
5.2
0.5
0.8
19
0.1
0.6
58
11
0.1
28
17
170,422
119
6.2
147,566
131,078
111,050
106,285
91,374
88,533
86,345
78,187
71,130
50,249
175
342
60
369
142
447
171
601
506
168
3
29
14
30
7.6
50
7,1
60
6
≦0.05
Persons
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
India
China
Indonesia
Nigeria
Bangladesh
Pakistan
South Africa
Ethiopia
Philippines
Kenya
Democratic
Republic of
Congo
Russian
Federation
Vietnam
Tanzania
Brazil
Uganda
Thailand
Mozambique
Myanmar
Zimbabwe
Cambodia
Afghanistan
Ranking of estimated incidence rates
HIV
infection
rate among
HIV
carriers
Persons
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
*22 high-burden countries stipulated in 1998
39
40
41
42
43
44
45
46
47
48
49
50
44
Swaziland
Djibouti
Namibia
Lesotho
Botswana
Kenya
Zimbabwe
South Africa
Zambia
East Timor
Cambodia
Sierra Leone
Mozambique
Malawi
Ivory Coast
Republic
of
Kiribati
Togo
Uganda
Congo
Rwanda
D R Congo
Ethiopia
Tanzania
Burundi
Central Africa
Gabon
Haiti
Tuvalu
Liberia
Mauritania
Philippines
Nigeria
Eritrea
Mali
Chad
Angola
Senegal
Papua
New
Guinea
Gambia
Indonesia
Guinea
Madagascar
Equatorial Guinea
Sudan
Bangladesh
Somalia
Burkina Faso
Bolivia
Guinea Bissau
Ghana
Ratio
(100,000)
HIV
infection
Rate
among HIV
carriers
13,029
6,045
14,164
12,489
11,551
219,582
78,187
284,538
70,026
5,261
71,130
26,266
88,533
52,751
69,417
378
1,262
762
697
696
654
641
601
600
600
556
506
475
447
409
382
380
75.0
16.1
56.2
64.5
69.9
528.0
60.2
58.1
55.1
22,910
106,285
14,659
32,627
204,977
266288
131,078
25,188
12,670
4,256
26,051
32
9,894
9,146
241,879
371,642
12,409
37,558
26,482
42,849
29,699
14,689
373
369
367
361
356
344
342
334
314
308
305
305
301
298
291
283
282
278
272
269
255
250
16.7
30.0
25.0
16.0
16.7
10.6
29.3
16.8
41.9
33.9
11.6
3,677
532,871
22,175
43,515
1,172
82,964
321,996
18,442
29,538
19,329
3,272
45,328
242
239
236
234
233
228
227
224
223
211
206
205
13.1
0.8
8.5
3.0
16.6
8.8
0.1
5.0
11.0
0.8
19.1
12.2
6.0
8.7
50.4
49.6
24.1
17.3
4.0
0.1
19.4
12.7
9.6
17.9
0.2
5.2
9.7
Figure 3 – 1: Estimated TB incidence rates – WHO (2005)
Areas with high HIV
prevalence in TB cases
Source: WHO Report 2007: Global TB Control Surveillance, Planning, Financing
Figure 3 – 2: Estimated TB/AIDS co-infection rates – WHO (2005)
Areas with high HIV
prevalence in TB cases
Source: WHO Report 2007: Global TB Control Surveillance, Planning, Financing
Figure 3 – 3: Progress in high burden countries
45
Treatment success (%)
Case Detection Rate (%)
Source: WHO Report 2007
Figure 3 – 4: Aid priority countries of TB control and JICA’s cooperation outcome
JICA’s cooperation
Technical cooperation
/(Advisor)
Dispatch of JOCV
Training in Japan
TB high burden countries (22 countries)
Icidence rate ≧280
TB high burden countries: Incidence rate
≧280
Grant aid
46
3 – 1 – 2: Place an emphasis on the strengthening the quality of DOTS
JICA renders cooperation to capacity development through the expansion and
strengthening of the DOTS strategy, which are the goals of MDGs and the HDI, so that
the government of the recipient country will be able to achieve a “case detection rate of
70% of estimated sputum smear-positive patients and a treatment success rate of 85% of
sputum smear-positive patients.” In particular, JICA adopts an approach to increase
the case detection rate while maintaining a high treatment success rate by making the
maximum use of the strategies unique to DOTS. (Prevention of multidrug-resistant
tuberculosis – Please refer to Chapter 2: 2 – 2 – 2 “(1) Multidrug-resistant TB control.)
JICA will focus upon the following measures:
2. Key approaches in strengthening the quality of DOTS
To reach the MDGs, JICA will take an approach that focuses upon the following
issues so that the government of the recipient country will be able to expand the
DOTS strategy and achieve the improvement of case detection rate while
maintaining a high treatment success rate.
(1) To improve monitoring, evaluation and supervision under the national
tuberculosis program
Capacity building that enables the government of the recipient country to track
down problems and operate the program while solving the problems on its own
(2) Improvements in the system of sputum microscopy and external quality
assurance in the area of laboratory
To improve sputum smear microscopy, which forms the foundation of TB
control: To introduce and improve a management system of external quality
assurance to control the quality
(3) To strengthen the logistics system of anti-tuberculosis drugs and testing reagents
etc.
3 – 1 – 3: Support the Beyond DOTS strategy
From the perspective of human security, JICA supports measures to deliver TB
control services to people who have difficult accessibility to public health and medical
facilities. In the past, JICA rendered cooperation to Community DOTS, urban
tuberculosis control, TB/HIV control measures, the implementation of a model project
for PPM, and the formulation of guidelines and capacity development through OJT at
the model site so that the NTP would acquire the management capacity of the Beyond
DOTS strategy. Such cooperation has manifested excellent effects.
As discussed in Chapter 2, the Beyond DOTS strategy contains measures to
further scale up the DOTS strategy. Thus, efforts should be made to improve the
47
quality of DOTS, which is at the heart of TB control, and only when it is certain that a
given level of the quality of DOTS can be maintained, various measures should be
adopted under the Beyond DOTS strategy.
In some countries, related governmental organizations lack the ability to
coordinate aid from donors. There are cases in which the Beyond DOTS strategy must
be started in parallel with the maintenance and expansion of DOTS even though it has
not been properly introduced and expanded. Thanks to the inflow of a large amount of
money from the GFATM, etc., it is now easier to implement some of the Beyond DOTS
strategies with support from international organizations or aid organizations than before
when the government was carrying them out with its own budget. In countries or
regions where the basic DOTS strategy has not been firmly established, there are a few
foreseeable risk factors. For instance, one is that DOTS may be carried out in a form
with a high probability of treatment failure. Another is that the payment of salaries to
volunteers at the peripheral level and funding to NGOs will build a new medical service
system in parallel with the existing public medical services, thereby incurring the risk of
preventing the development of the public medical service system of the recipient
country. It will be essential, therefore, to pay due consideration to these issues when
cooperation is rendered.
3 – 2: Notes concerning JICA’s cooperation policy on TB control
As for the approach to cooperation to “qualitative strengthening of DOTS” and
“support Beyond DOTS to scale up DOTS” in aid priority countries, the following
issues will be focused on, based upon JICA’s past experiences of providing cooperation
to many countries.
＜Notes concerning the JICA’s cooperation policy on TB control＞
1. To focus upon capacity development through human resource development and
system building
2. To pay special attention to ensure sustainability of maintaining and improving the
quality entailed in the TB control project
3. To introduce a system tailored for each country based upon the outcome obtained
from implementing a model project
4. To provide cooperation in accordance with the conditions of each aid priority
country by making the maximum use of the features of each scheme
5. To render cooperation in closer coordination with international organizations and
aid organizations
48
3 – 2 – 1: Cooperation primarily for human resource development, institution
building, and system building (i.e., capacity development)
Capacity development is one of the approaches to which JICA gives special
weight and has a comparative advantage relative to other international organizations and
aid organizations. Hence, it is a matter of course that it is of great importance in TB
control as well, and the approach will play the pivotal role. That is, JICA will provide
cooperation to the development of human resources related to governmental
organizations, system building such as DOTS and Beyond DOTS, and institution
building in which the national tuberculosis program is reinforced so that TB control can
be carried out properly in the country.
3 – 2 – 2: Secure the sustainability of the quality maintenance and improvement
entailed in the TB control project
The viewpoint of sustainability is a key part of any of JICA’s cooperation.
The DOTS strategy entails, so to speak, a built-in mechanism to detect and correct a
malfunction in TB control. JICA executes cooperation primarily for building a system
of monitoring, evaluation, and supervision simplified to meet the conditions of each
country and the development of human resources and institutions that are responsible
for external quality assurance.
3 – 2 – 3: Introduce a system modified for each country through implementing a
model project, etc.
DOTS and Beyond DOTS are universal concepts. However, these concepts
need to be modified in accordance with the budget, human resources, and health
administration system of each country. JICA’s cooperation will aim to build a
sustainable and appropriate system by making the maximum use of the limited
resources of each country based upon the result of model projects etc.
3 – 2 – 4: Make full use of the advantages of each scheme for effective cooperation
It is expected that JICA will be able to render effective cooperation by
integrating various schemes including technical cooperation project, grant aid, and
training courses based on the past cooperation relevant to health, and in particular,
tuberculosis.
In each aid priority country, JICA needs to select the best approach. There are
countries whose country-specific assistance plans and cooperation programs state that
TB control is a priority aid issue, whereas there are other countries where JICA has no
office or where its cooperation infrastructure is limited. Thus, depending upon the
conditions of each country, JICA needs to opt for either a selective combination of the
49
above schemes or cooperation that primarily focuses upon the training course.
In particular, in the case when all the above conditions to offer cooperation to
TB control are met, a technical cooperation program has a significant advantage in
impacting on policy making at the national level of the national tuberculosis control
program responsible for policy formulation and implementation. The core of the
program being a technical cooperation project, the whole program must be operated in
good coordination with other schemes. This form of program will be promoted
because it has been proven highly effective.
Grant aid
・Construction of a
TB center or
central TB center
・Provision of
anti-TB drugs and
microscopes
・Anti-TB drugs
・Microscopes
Aid to NGOs by local operation
expenses for the project (former
community empowerment
support)
Health center
National TB program
Province/prefectur
1. Formulation of TB control plan
and progress management
2. Formulation of guidelines and
training module
3. Monitoring, evaluation and
supervision
(Implementation of DOTS:
Lab. External Quality
Assuarance)
4. Logistics
County official in
charge of TB
Private
medical
facilities,
pharmacies
Health center
Technical cooperation project
Figure 3 – 5: Effective cooperation with full use of the features of each scheme
Village health
volunteers, etc.
DOTS
PPP, PPM
Community
DOTS
Urban district
Rural area
Tuberculosis patients
3 – 2 – 5: Cooperation in closer partnership with international organizations and
aid organizations
A massive amount of input is essential for strengthening nationwide TB control.
That is, it is difficult to strengthen the TB control of any country only through capacity
development, which typically characterizes JICA’s cooperation, unless some creative
50
ideas are added to designing the cooperation. Hence, it will be important to effectively
strengthen the national tuberculosis program in partnership with many related donors.
JICA has accumulated experience, produced excellent effects, and has a
comparative advantage in supporting the entire national TB program, and the
formulation of guidelines and training modules through a pilot project. Thus, towards
the eventual aim of nationwide reinforcement, it has been effective to form partnerships
with other donors which offer aid to scale up DOTS at the county level. In the case of
nationwide cooperation, JICA has supported monitoring, evaluation, and supervision of
projects towards quantitative expansion of operation while maintaining the quality of
the DOTS strategy. These approaches have proven effective and should be expedited
in the future (Figure 3 – 6).
51
Figure 3 – 6: Example for strengthening partnership with international organizations
and aid organizations
Conferences hosted by the national tuberculosis program (the field for adjustments)
JICA’s technical Cooperation Project
Workshop (sharing information among donors)
Cooperation for organizing a conference in which
all related donors participate under the initiative
of the national tuberculosis program
1.
2.
3.
4.
Formulate a TB control
program and progress
management
Formulate
guidelines
and training modules
Monitoring, evaluation,
and supervision
(Implement
DOTS;
LAB external quality
assurance)
Logistics
WHO support for the
formulation of
guidelines
National TB program
Province/prefecture
Financial aid from
the GFATM
County official
in charge of TB
Health center
Health center
Financial aid per
district from the
common basket
Private medical
facilities,
pharmacies
Village health
volunteers, etc
DOTS
PPP, PPM
Community
DOTS
Rural area
Tuberculosis patients
52
Support for the
implementation to
NGOs
from
USAID
Urban district
Food supply to TB
patients under
treatment from the
WFP
3 – 3: Issues concerning the execution of JICA’s cooperation policy on TB control
The problem of TB still imposes a heavy burden upon developing countries.
Yet, the global goals to eradicate TB have not been achieved. There is great need for
cooperation in the future. This chapter looks into JICA’s cooperation policy on
tuberculosis and relevant notes to be kept in mind in “3 – 1” and “3 – 2.”
＜Issues concerning the execution of JICA’s cooperation policy for TB control＞
■Strengthen the implementation system
1. A cooperation program to meet the needs and conditions of each country should be
systematized.
・Measures for new schemes of cooperation in DOTS
・Measures for sub-Saharan Africa and countries after the end of civil war
・Effective use of loans
2. Input resources must be developed and strengthened.
3. Information collection and transmission must be strengthened.
4. The implementation system to deal with new issues needs to be strengthened.
3 – 3 – 1: To systematize cooperation programs to meet the needs and conditions of
each country
(1) Measures for new schemes of cooperation in DOTS
Since 1995 when DOTS was established, many countries have been taking
measures, more or less, to carry out TB control under DOTS. It is assumed that
JICA will receive requests under a new scheme of cooperation in the future as will
be discussed below. Hence, JICA needs to refine its approach to satisfy the
requests.
JICA does not have much experience in the areas discussed in this section. It is
necessary to accumulate experience through the formulation and implementation of
each project.
1) Cooperation for a specific region of a target country
Many countries have been already carrying out the DOTS strategy at the
national level. In the future, therefore, it is considered that JICA will be
requested to render cooperation to one component of DOTS in a specific region.
Also, in all likelihood, the number of requests to provide cooperation to a
specific region, rather than to the central government, will increase from
countries where a federal system is adopted or decentralization has advanced.
In this case, JICA needs to come up with a new idea on how to diffuse the
53
benefits limited to the region of cooperation or the site of a model to other areas
in the nation.
2) Partial cooperation for DOTS
It is likely that JICA will receive requests to provide cooperation to the sector of
laboratory and diagnosis, which is one of the components of DOTS, or to the
strengthening of Community DOTS, urban tuberculosis, or PPM, which comes
under Beyond DOTS. All these cases cover only a part of TB control measures.
Hence, it is essential how JICA will be able to provide cooperation in
coordination with national tuberculosis control.
(2) Measures for sub-Saharan Africa and countries after the end of civil war
1) Sub-Saharan Africa (TB/HIV control)
The countries with high estimated TB incidence among aid priority countries
fall in line with the counties in sub-Saharan Africa with high HIV infection rates.
Thus, there is great need for cooperation in the countries in this region because
their general infectious disease control measures lag behind. JICA has some
experience in extending technical cooperation projects to the laboratory in TB
control in sub-Saharan Africa. However, cooperation has been primarily
directed to training health personnel in Japan.
In the future, it is important to understand the characteristics of each region in
order to strengthen JICA’s cooperation system in sub-Saharan Africa. For
instance, SWAPs, common basket, and decentralization have been introduced in
a number of countries. As a result, cooperation is now given to strengthen the
county’s health service system and funds are also funneled into the county.
(Recently, a change is ongoing to replace sector-based funding with nation-based
funding. However, the fact remains that the powers to implement projects have
been transferred to the county, which is an administrative unit of health
administration.) Among donor countries that promote SWAPs, TB control and
AIDS control are handled as a vertical program. In countries where TB control
functions successfully under the vertical program, their central governments
attach importance to monitoring, evaluation, and supervision toward lower
administrative organizations in the prefecture or county in order to maintain a
high quality of DOTS throughout the nation. As a result, the TB control
capacity of the prefecture and county has been standardized at a high standard.
In sub-Saharan Africa, on the other hand, the central government is not much
involved in lower administrative organizations.
In the technical cooperation projects that JICA implemented in countries other
than those in sub-Saharan Africa, its counterpart was the central government
54
(TB Control Div. or Infection Disease Control Div. of the Ministry of Health)
based upon the reasoning that importance lies in the monitoring, evaluation, and
supervision for the quality control of DOTS in order for the government of the
recipient country to improve the quality of TB control. However, in
sub-Saharan Africa, the central government’s authority has been restricted, and
moreover, the outflow of personnel has been on the increase in parallel with
decentralization, thereby thinning out the personnel that formed the main layer
of JICA’s counterparts. In some cases, technical cooperation project receives a
negative response from other related donors and from the government of the
recipient country where the common basket has been applied. Thus, it is
difficult to render cooperation using the schemes or designs adopted for Asian
countries. It is necessary to incorporate new ideas.
The key to cooperation in the future lies in the way in which the function to
monitor, evaluate, and supervise the quality of DOTS is incorporated into the
DOTS strategy currently implemented in the county.
＜Possible schemes of cooperation＞
① To build a management system (monitoring, evaluation, and supervision
system) of the TB control system at the county level under decentralization
② To offer cooperation to the central government focusing upon collecting
good practice at the local or field (county) level ➝ Support for
systemization ➝ Support for dissemination
③ To select a specific field of TB control and then build good practice at the
local/county level ➝ Support for systematization ➝ Support for
dissemination
④ To render cooperation to TB control as part of the development of public
health and regional medical systems
2) Countries after the end of civil war
In such countries as Cambodia and Afghanistan where TB control has been
neglected for a prolonged period of time among aid priority countries, the
number and incidence rate of TB-infected persons have been on the increase.
Immediately after the end of civil war, a country is faced with problems: the
health and medical system is fragile; there are many security restrictions; and aid
is conducted under special conditions where NGOs take over a public medical
system such as contract-in/out. 46 Thus, it is required to formulate a project
46
This is an approach in which an NGO is commissioned to deliver health and medical services in a health
administrative district. The content of the services varies by country, but the NGO, consignee, receives a
commission in a lump sum, with which the NGO procures the necessary materials and pays wages to health workers
(which is decided based upon the standard set from the perspective of whether or not it is enough to sustain livelihood
55
considering which scheme of cooperation is most suited to the conditions of
each country.
On the other hand, there is great need for other disease control as well as TB
control in these countries. Hence, it is essential to examine the possibility of
cooperation based upon cooperation priority in the entire field of health and the
features of TB control and add new ideas to schemes of cooperation. One
particular feature of TB control is that half measures only cause more serious TB
damage. Thus, it is essential to take measures to strengthen TB control with
the following points in mind: it takes a period of 6~8 months for medication for
a patient to be treated; during this period, medical professionals must thoroughly
follow TB-infected persons; and if there is no follow-up system, drug-resistant
TB may spread extensively.
For instance, during the emergency rehabilitation period immediately ensuing
the end of civil war, it is possible to formulate a program in partnership with
related NGOs, consignees of contract-in/out (responsible for delivering health
administration services at the county level), and international development
fiancé organizations (in particular, the Japan Social Development Fund of the
WB and the Japan Fund for Poverty Reduction of the ADB).
(3) Collaboration with loans
Together with reforms in Japan’s ODA implementation system, JICA needs to
pave the way for the full utilization of yen loans by paying greater attention to their
more effective and inclusive use. In the area of TB control, JICA has experience in
forming partnerships with international fiancé organizations such as the WB and
ADB in strengthening the supply of anti-tuberculosis drugs. JICA has also worked
in collaboration with health sector-based loans. Upon formulating a project for this
area, the relevance is explained based upon the reasoning that people’s improved
health conditions will eventually lead to alleviating declining GDP although the
direct reimbursement of expenses cannot be expected, unlike toll roads and electric
power plants. It will be important to collect and analyze information on these
cases.
3 – 3 – 2: Development and strengthening of input resources
It is assumed that requests for cooperation will increase in number and may
change in content in the future. It is urgently required to expand human resources.
or whether a worker is able to devote him/herself to his/her work as opposed to the wages of public officials which
are normally kept low). The approach has validity during a postwar emergency rehabilitation period, but may
foment dependency in terms of the payment of wages and in developing the capacity of the county administration and
management that should essentially be responsible for providing these health services.
56
The Issue-based Department should standardize the Plan of Operation for improving the
quality of DOTS and Beyond DOTS and clarify the contents of work required for each
expert and the time of dispatch. Based upon the outcome, it needs to find and develop
the necessary human resources. As regards the development of new projects in the
future, as discussed above, it is believed that JICA will receive an increasing number of
requests to provide cooperation to TB control in a part of a region or an area as well as
the entire national tuberculosis project. It is important to analyze and standardize the
feasible contents of cooperation and to explore and develop human resources who are
able to fulfill these requirements.
JICA has been in the middle of expediting reforms subsequent to its
reorganization as an independent administrative corporation. That is, JICA aims to
achieve more efficient implementation of projects and greater performance. At present,
the Issue-based Department has also been promoting raising efficiency in its
medium-range plan. As one approach, it proposes and promotes technical cooperation
project under contract with a private organization.
3 – 3 – 3: To strengthen information collection and transmission concerning DOTS
As explained in Chapter 1, the Stop TB Partnership has been playing the
pivotal role in international cooperation in the area of tuberculosis. In the past, JICA
took many opportunities to dispatch experts of projects carried out in various countries
to the meetings of the Stop TB Partnership. In the future, JICA should take the role of
transmitting information in the area of health as well as tuberculosis on every occasion
including international conferences. In particular, based upon the conditions of
counterparts learning from experience in cooperation projects in many countries, JICA
should stress the importance of DOTS strategy at the core of TB control.
JICA has been aware of the significance of the basic DOTS strategy and has, in
fact, produced a good outcome in many countries. Since the time when more funds
started to come into the area of HIV/AIDS control, there are cases here and there in
which the basic DOTS is neglected. There is a movement to draw international
cooperation, for instance, by giving a new attention-getting name to a component
constituting TB control. This movement is a measure for developing countries in want
of various resources to obtain new input, and cannot be totally denied because it has
elements that contribute to strengthening TB control. On the other hand, from the
viewpoint of sustainability, it is essential to continue cooperation that is based on the
recognition that the Beyond DOTS strategy can be built upon the DOTS strategy
underlying TB control, as has been done by JICA. For instance, the expansion of TB
control under the circumstances in which the treatment success rate is still low may end
up in an epidemic of multidrug-resistant tuberculosis.
57
In the field in many countries, international aid coordination and donor
meetings are frequently carried out in the areas of health and infectious disease control.
Each of JICA’s offices has been taking an active part in them. The project side has
been asserting the importance of DOTS in the field and aid coordination meetings for
TB control. In the future, it will be necessary for JICA to take a step forward. That is,
it should increase opportunities to emphasize more strongly the importance of aid to the
DOTS strategy through making a summary report of JICA’s cooperation at international
conferences.
3 – 3 – 4: To strengthen the implementation system to address new challenges
In order to address the issues discussed in the Sections “3 – 3 – 1” to “3 – 3 –
3,” it is essential to strengthen the Issue-based Department, overseas offices, experts,
and contract organizations further. Since the start of the GFATM, the area of
tuberculosis has been undergoing changes in the concept of public health: from a global
viewpoint, it is expected that there may be a considerable change in the DOTS strategy
due to new anti-tuberculosis drugs and testing reagents under development; and striking
and rapid changes have been already taking place including control for super strains of
multidrug-resistant tuberculosis that goes beyond MDR-TB and HIV/AIDS control
measures. Additionally, an international coordination system has been further
strengthened.
JICA needs to explore how it will be able to reinforce its
implementation system. For instance, it should have a good grip on global standards
and trends and effectively incorporate them into its cooperation; it should consider the
possibility of establishing an issue-specific committee for health and medicine
(tuberculosis) constituted of Japan’s related organizations and resources for the purpose
of transmitting JICA’s cooperation policy.
58
＜Bibliography＞
1. Masakazu Aoki: Tuberculosis science for physicians and nurses 1 – Basic knowledge
(Revised in 2004), Japan Anti-tuberculosis Association: 2004
2. Masakazu Aoki: Tuberculosis science for physicians and nurses 3 – Principles and practice
of chemotherapy①, Japan Anti-tuberculosis Association: 2004
3. Masakazu Aoki: Tuberculosis science for physicians and nurses 4 – Principles and practice
of chemotherapy②, Japan Anti-tuberculosis Association: 2004
4. Masakazu Aoki: Visual Note on Basic Knowledge of Tuberculosis (Revised in 2001), Japan
Anti-tuberculosis Association: 2001
5. Naomi Toyokichi: Conditions and leadership in cooperation to Health SWAPs – Based upon
a case study of SWAPs in Ghana (Report by JICA’s Associate researcher: 2002)
6. WHO Report 2005: Global TB Control Surveillance, Planning, Financing
7. AIDS Clinical Center, International Medical Center o Japan: Support to Anti-HIV therapy
and medication: 2002
8. WPRO/WHO: Reaching the poor; challenges for the TB programmes in the Western Pacific
Region. 2004
9. ICMR Bulletin: Tuberculosis and Poverty. Vol. 32 No. 3 March, 2002. ISSN 0377-4910
10. WHO: A human rights approach to TB. Stop TB Guidelines for Social Mobilization.
WHO/CDS/STB/2001.9
＜Homepage＞
Tuberculosis Fact sheet N°104 (Revised March 2006)
http://www.who.int/mediacentre/factsheets/fs104/en/#infection
Stop TB Partnership
http://www.stopth.org/
The International Union against Tuberculosis and Lung Disease
http://www.iuatld.org/full_text/en/frameset/frameset.phtml
Global Fund to Fight AIDS, Tuberculosis and Malaria (FGATM)
http://222.theglobalfund.org/en
59
Appendix 1: Major examples of cooperation
Appendix 2: Basic check items
Appendix 1: Major examples of cooperation
Table A1 – 1: Projects of project-type technical cooperation in the area of TB control
Country
Afghanistan
Name of project
TB control project
Duration
2004-2009
Nepal
TB control project
(Phase 1)
1987-1994
TB control project
(Phase 2)
1994-1999
Community tuberculosis
and lung health project
(Phase 3)
2000-2005
Public health project
1992-1997
TB control project
1997-2002
TB control improvement
project
2002-2007
Solomon
Islands
Primary health
promotion project
1991-1996
Yemen
TB control project
(Phase 1)
TB control project
(Phase 2)
1983-1992
TB control project
(Phase 3)
1999-2004
TB control project
(Phase 1)
2000-2004
Philippines
Cambodia
care
1993-1998
Content and characteristics
To promote the national TB control project, primarily in
disseminating DOTS through strengthening NTP and NTI
in partnership with other donors and NGOs, cooperation
for processes of formulating National. TB Strategy,
guidelines, annual plan at the government level.
Assistance for the integration of the Nepal National
Tuberculosis Control Program in collaboration with the
construction of the National Tuberculosis Center
(Kathmandu) and the Regional Tuberculosis Center
(Pokhara) with grant aid
Technical cooperation for the implementation of DOTS by
using the existing health system at the model site and
designing a DOTS model in mountainous regions that are
not easily accessible geographically
To ensure medical treatment under the DOTS strategy
through strengthening the referral system and expanding
diagnostic and treatment bases: To build a model for urban
tuberculosis control in Kathmandu: To carry out various
activities including acute respiratory tract infectious
disease control among children through IMCI under the
DOTS strategy
A model project to introduce DOTS in the Province of
Cebu
Cooperation for the nationwide operation, based upon the
above project
To operate the monitoring, evaluation, and supervision
system and the laboratory network system nationwide: To
show how to supervise NTP in regions where the
performance of DOTS is poor
To strengthen the health system using the approach taken
in PHC: To develop human resources in the area of health
and medicine: To enhance health education: To control
infectious diseases including malaria and TB through C/P
training
To build the foundation of the TB control system, thereby
contributing to detecting TB patients
The project was temporarily interrupted because of civil
conflict. The DOTS strategy that was introduced after its
resumption produced a marked improvement in treatment
success in the model region.
To strengthen the laboratory service network in order to
expand national tuberculosis services nationally: To
improve TB treatment by proper management of patients:
To improve the supply system of medicines by establishing
a stock control system: To improve the monitoring system
by standardizing the record-keeping and reporting system
To expand the DOTS services to the health center: To
strengthen TB/HIV control: To take measures for
Community DOTS
TB control project
(Phase 2)
2004-2009
Zambia
AIDS and TB control
project
2001-2006
Myanmar
Project for infectious
disease control
2005-2010
Pakistan
TB control project
2006-2009
To address the issue of PPM mainly in Phnom Penh: To
improve the quality of DOTS: To strengthen TB/HIV
control measures
To provide assistance to the laboratory at Zambia
University Teaching Hospital: To carry out research for
making a policy proposal concerning TB/HIV control
measures: To strengthen the examination function for
external quality control of sputum smear microscopy
To visit each community and play a guiding role in
improving the quality of DOTS: To develop and
disseminate a TB control module at the township level: To
hold training for laboratory technicians: To spread
knowledge about TB control to the family and community:
To build relationships with private medical facilities: To
formulate and distribute a DOTS handbook
To improve the monitoring and evaluation of DOTS
implemented by the central and state governments
focusing upon the State of Punjab and the TB program
carried out by the Ministry of Health: It is planned to
render cooperation for improving the supervising method,
sputum microscopy, and quality assurance
Table A1 – 2: Grant aid projects for TB control
Project
Fiscal
year
1994
Amount
Content
259
million
Cambodia: Project for Infectious
Disease Control
Cambodia: Project for Infectious
Disease Control
Cambodia: Project for Infectious
Disease Control
Cambodia: Project for Improvement
of the National Tuberculosis Center
in the Kingdom of Cambodia
Nepal: Project for the Construction of
the National Tuberculosis Center
2003
395
million
232
million
278
million
803
million
Equipment to upgrade TB diagnosis (CT
scanner, clinical biochemistry analyzer,
radiography, gynecological laparoscopy,
thoracoscopy, bronchoscopy, and compact
ultrasonic diagnostic apparatus)
Purchase of anti-tuberculosis drugs,
vaccines, and cold chain
Procurement of anti-tuberculosis drugs
1987
1,431
million
Haiti: Project for Improvement of
Medical Equipment
Haiti: Project for Tuberculosis
Elimination
Bangladesh: Project for Improvement
of Medical Equipment
1984
320
million
600
million
681
million
Philippines:
Project
for
the
Establishment of the National
Tuberculosis Institute
China: Project for Improvement of
Equipment for the Tibet Tuberculosis
Control Center
China: Project for Tuberculosis
Control in Poor Areas (Phase II)
2000
415
million
Construction of the Tuberculosis Control
Center and Cigno Sanatorium
Medical equipment and vehicles for
health centers such as the tuberculosis
HQ, research/training institute, and
tuberculosis center
Construction of the National Tuberculosis
Institute and provision of equipment
1994
709
million
Radiography, spectroscopy, endoscopy,
medical check-up vehicle, and computers
2002
402
million
China: Project for Tuberculosis
Control in Poor Areas (Phase III)
2003
449
million
China: Project for Tuberculosis
Control in Poor Areas (Phase IV)
2004
405
million
China: Project for
Control in Poor Areas
Tuberculosis
2000
321
million
Honduras: Project for Improving
Medical Equipment at the National
Health Laboratory
2004
146
million
Zambia: Infectious Disease Control
Project
2003
51
million
Purchase of anti-tuberculosis drugs and
laboratory equipment in nine provinces
and three autonomous districts
Purchase of anti-tuberculosis drugs and
laboratory equipment in nine provinces
and three autonomous districts
Purchase of anti-tuberculosis drugs and
laboratory equipment in nine provinces
and three autonomous districts
Purchase of anti-tuberculosis drugs and
laboratory equipment in nine provinces
and three autonomous districts
Procurement of clinical laboratory
equipment for the central and regional
laboratories to strengthen clinical testing
capacity
for
infectious
disease
surveillance
Procurement of anti-tuberculosis drugs
and reagents and health center kits
(diagnostic toolbox) for diagnostic tests
Indonesia:
Project
for
the
Improvement of Medical Equipment
at Persahabatan Hospital
2004
2005
1999
1981
1987
Collaboration
with projecttype coop.
(Long-term
expert)
●
●
Procurement of anti-tuberculosis drugs
●
Remodeling of the facilities of the
National Tuberculosis Center
●
Construction of the National Tuberculosis
Center and Community Tuberculosis
Center
●
●
●
Zambia: Infectious Disease Control
Project (Phase II)
Swaziland: Project for Improving
Health Care Service
2004
Swaziland: Project for Improving
Health Care Service
1999
161
million
Afghanistan: National Tuberculosis
Control Project
Armenia: Project for Improvement of
Medical Equipment
Yemen: Project for Expansion of the
National Tuberculosis Center
Yemen: Project for Expansion of the
National Tuberculosis Center
Yemen: Project for Expansion of the
National
Tuberculosis
Control
Program
Yemen: Project for Expansion of
Tuberculosis Control in the Southern
Govemorate
1977
75
million
495
million
918
million
108
million
508
million
2000
564
million
Yemen: Project for Expansion of
Tuberculosis Control in the Southern
Govemorate
2002
589
million
1997
2001
1984
1985
1991
415
million
415
million
Procurement of reagents for diagnostic
tests
Procurement of medical equipment for the
Tuberculosis Center (medical equipment
and X-ray film viewers used at Clinical
Laboratory and Radiography Dept.)
Procurement of medical equipment for the
Tuberculosis Center (medical equipment
and X-ray film viewers used at Clinical
Laboratory and Radiography Dept.)
Construction of the National Tuberculosis
Institute and the Tuberculosis Center
Provision of medical equipment to the
Republic TB Hospital
Construction of the Tuberculosis Center
●
Construction of the Tuberculosis Center
●
Remodeling of the TB sub-center and
procurement of medical equipment for it
●
Facilities for education/training for
persons involved in TB control and
Mycobacterium testing and researches
(Aden)
Education/training facilities for persons
involved in TB control and diagnostic
tests and researches (Aden)
●
Note: BCG is excluded from the above list because it is included in the EPI project.
●
●
●
Table A1 – 3: Dispatch of JOCV members for strengthening TB control
Duration of
dispatch
Occupation
Content of request (including plans)
Workplace assigned to
the volunteer
Honduras
1991.12
~1993.12
Public health
nurse
The First Hygiene
Region, Ministry of
Health and Social
Welfare
Bangladesh
1992.7
~1994.7
Public health
nurse
Guatemala
1992.1 ~
1995.1
Nurse
Samoa
1992.1 ~
1996.1
Clinical
laboratory
technologist
Bangladesh
1992.1 ~
1994.12
Public health
nurse
Bangladesh
1992.12
~1994.12
Clinical
laboratory
technologist
Ivory Coast
1993.4 ~
1995.4
Public health
nurse
There is one district hospital and 13 health centers
in the Department of Gracias a Dios in the
northern part of Honduras. This is the most
underdeveloped area. The JOCV member is
expected to give education to practical nurses
working in the area on heath activities, health
statistics, and infectious disease control
(especially TB).
It is expected to give health education to patients
and staff at the central organizations related to
TB. Responsibilities include making a plan,
enforcing the plan, and preparing teaching
materials. The JOCV nurse visits 42 TB clinics
in local areas and trains instructors (unlicensed)
It is expected to show nine registered nurses and
106 practical nurses in the hospital how to give
nursing care and treatment to TB patients and
ICU patients. It is also expected to hold lectures
and study groups to impart knowledge of nursing,
thereby raising the level of awareness about
nursing.
Responsibilities include the establishment of
diagnostic tests (ZN coloring and identification in
bacterial culture) in the Bacteriology Section of
the Laboratory at the National Central Hospital,
carrying out routine bacteriology, and teaching the
techniques to students.
It is expected to give health education to patients
and staff at the central organizations related to TB
control. Responsibilities include making a plan,
enforcing the plan, and preparing teaching
materials. The JOCV nurse needs to visit 42 TB
clinics in local areas and train instructors
(unlicensed).
It is expected to give education to laboratory
technologists primarily at the center (on
bacteriological testing). The JOCV member is
also expected to visit, together with nurses who
go for their nursing activities, local areas to teach
local laboratory technicians. The laboratories
are well equipped with equipment and supplies
provided by Japan. It is expected to teach the
techniques of culture and resistance tests of
tubercle bacilli.
The JOCV member is assigned to Pakobo Clinic
under the jurisdiction of the Medical Office in the
Tiassale region with a JOCV midwife. It is
expected to carry out clinical activities in
cooperation with local nurses. He/she will also
visit villages within a range of 15 km and provide
medical service and vaccination as well as
Country
Tuberculosis
Prevention Center,
Ministry of Health
and Family Welfare
San Vicente TB
Hospital, Ministry of
Welfare
National Hospital,
Ministry of Health
Tuberculosis
Prevention Center,
Ministry of Health
and Family Welfare
Tuberculosis
Prevention Center,
Ministry of Health
and Family Welfare
Medical Office in
Tiassale, Ministry of
Health and Welfare
Honduras
1993.7 ~
1995.7
Public health
nurse
Ivory Coast
1993.1 ~
1995.12
Clinical
laboratory
technologist
Solomon
Islands
1994.4 ~
1995.1
Nurse
Malawi
1995.4 ~
1997.7
Nurse
Cambodia
1995.7 ~
1997.7
Public health
nurse
Samoa
1995.1 ~
1998.3
Clinical
laboratory
technologist
Malawi
1996.4 ~
1998.4
Clinical
laboratory
technologist
Dominican
1996.4 ~
Public health
teaching control measures of endemic diseases
(leprosy, TB, and onchocerciasis) and hygiene.
Infectious diseases in general: It is expected to
spread knowledge and skills about infectious
disease control, particularly TB, acute respiratory
infectious diseases, cholera, and AIDS, to
community practical nurses, midwives, health
volunteer workers, and residents, individually or
in groups: Especially requested is cooperation
for TB control.
The JOCV member is assigned to the Medical
Office in the Tiassale region to carry out routine
laboratory activities and enhance the function of
the laboratory. The Office is responsible for
endemic diseases (leprosy, TB, onchocerciasis,
and Schistosoma haematobium) control. Thus,
he/she will conduct sputum, blood, and urine tests
related to these diseases.
It is expected to conduct diagnosis, treatment
(including suture), checkup on pregnant women
and infants, vaccination, and follow-up of TB
patients at the clinic within the Noro District
Community Center. It is also expected to give
education on health to community residents.
The JOCV nurse is assigned to a Christian general
hospital, with 170 beds in total, consisting of
General Practice, Obstetrics, and a TB wing and
also a nursing college. It is expected to teach
and advise the staff about the management of
pharmacy, inventory of medicines, and
medication to outpatients and in-hospital patients.
It is also to teach and advise the staff of the
pharmacy about the supply of medicines at the
health center in the district.
This cooperation constitutes a part of the rural
development project provided through triangle
cooperation with the four ASEAN countries
(Indonesia, Malaysia, the Philippines, and
Thailand). He/she is based at clinics in villages
within the target area and carries out activities of
teaching about public health including PHC,
MCH, TB/malaria control, and ARI control to
residents.
The Laboratory carries out mycobacterium tests
(Z-N coloring and culture). It is expected to
teach techniques to a local staff so that the
Laboratory will be able to conduct tests including
drug sensitivity tests.
It is a general Christian hospital located within 20
km of Blantyre. It consists of General Practice,
Obstetrics, and a TB wing. It is expected to raise
the level of microscopic techniques (liver
function, urine, and stool) through technical
guidance and teaching the management of testing
reagents to the staff.
The Office has jurisdiction over public health and
The First Hygiene
Region, Ministry of
Public Health and
Social Welfare
Medical Office in
Tiassale, Ministry of
Health and Welfare
Noro Clinic,
Government of
Western Province
St. Joseph’s Hospital,
Ministry of Health
Ministry of
Development
Rural
Central Laboratory,
National
Hospital,
Ministry of Health
Mulanje
Mission
Hospital, Ministry of
Health
The Fourth Regional
Republic
1998.4
nurse
Honduras
1996.4 ~
1998.4
Public health
nurse
Paraguay
1996.4 ~
1998.4
Public health
nurse
Solomon
Islands
1997.7 ~
1999.7
Nurse
Dominican
Republic
1997.7 ~
1999.7
Public health
nurse
Marshall
1997.7 ~
1999.12
Nurse
Malawi
1998.4 ~
2000.4
Clinical
laboratory
technologist
Malawi
1998.1 ~
2000.12
Public health
nurse
social welfare in the four provinces in the
southwestern part. The JOCV nurse is expected
to give medications and advice on living to TB
patients, and visits hospitals and clinics for
guidance. In cooperation with local nurses,
he/she also teaches about family planning and
provides vaccinations.
While working at the public health center under
the jurisdiction of the Office, the JOCV member
carries out public health extension activities
including TB control to residents, health
volunteers, and practical nurses who work at
public health centers. Preventive education is
provided individually or in groups depending
upon the specific needs of each area.
The JOCV nurse is assigned to the Health
Division of the Regional Medical Center and
gives education to medical professionals and
people involved in maternal and child health, TB
control, and genital disease control, thereby
enhancing the overall level of medical service in
the Department of Paraguari.
The Noro Clinic is responsible for the Noro
District on New Georgia Island and neighboring
islands.
The JOCV nurse is engaged in
diagnosis, drug prescription, treatment of slight
wounds including suture for outpatients, checkup
of pregnant women and checkup of infants,
vaccinations, and follow-up of TB patients.
She/he is also involved in regional health and
health education.
The JOCV nurse carries out activities in public
health to nurses of clinics and health extension
workers in the region. He/she tries to expand
local medical service based upon the national
plan, “Improvements in TB control, expansion of
inoculation, family planning, and maternal and
child health.”
The JOCV nurse works at a general hospital in the
capital (with 85 beds, 11 doctors, and 139 nursing
members) and is engaged in daily clinical nursing
together with the local staff so as to raise the level
of nursing skills. The main diseases treated by
Internal Medicine include diabetes, high blood
pressure, pneumonia, and tuberculosis.
It is a general Christian hospital and consists of
General
Outpatients,
Pediatrics,
Surgery,
Gynecology and Obstetrics, and a TB wing. It
has 250 beds. In the hospital’s laboratory, the
JOCV member supports its staff in blood, urine,
stool, and marrow tests and bacteriological tests
due to a high prevalence rate of infectious
diseases.
The JOCV nurse carries out activities at the health
center under the jurisdiction of the government’s
local hospital equipped with 190 beds and
Office, Ministry of
Health and Social
Welfare
The First Hygiene
Regional
Office,
Ministry of Health
Public Health Center
in Paraguari, Ministry
of Health
Noro Clinic,
Medicine and
Welfare Bureau of
Western Province
Office in Valverde D.
N., Ministry of
Welfare
Majuro Hospital,
Ministry of Health
and Environment
Muranje
Mission
Hospital, Ministry of
Health
Lobi Health Center,
Dedza District
Hospital, Ministry of
Bolivia
1998.1 ~
2000.6
Public health
nurse
Maldives
1999.4 ~
2001.4
Clinical
laboratory
technologist
Malawi
1999.4 ~
2001.4
Pharmacist
Malawi
1999.4 ~
2001.4
Clinical
laboratory
technologist
Malawi
1999.4 ~
2001.4
Pharmacist
Malawi
1999.4 ~
2001.4
Physical
therapist
Malawi
1999.4 ~
Physical
consisting of General Practice, Obstetrics,
Pediatrics, and a TB wing. It is expected to
improve residents’ nutrition and hygiene through
teaching what and how should be cooked and
eaten in order to expand the latitude of farmers.
The JOCV nurse is assigned to the only clinic in a
village of about 1,000 people. He/she gives
cooperation through holding lectures or visiting
individual houses, together with his/her
counterpart, on the health program, vaccination,
TB control, and family planning.
The JOCV member carries out laboratory work
with an Indian technician and Maldivian assistant.
The main tests include general urine tests, urinary
sediments, general blood tests, parasites, tubercle
bacilli, malaria, group bacterial drug sensitivity
tests, group-bacilli drug sensitivity tests, and
biochemical tests. It is also expected to train the
assistant.
The hospital is a Christian general hospital with
178 beds and consisting of General Practice,
Obstetrics, Pediatrics, and a TB wing. Malawi
has a chronic shortage of pharmacists. The
JOCV member, as the responsible person in
charge of the pharmacy, extends cooperation in
the procurement of medicines, inventory control,
and dispensing of medicines (drugs dispensed at
the counter and in the hospital).
The JOCV member works at a Christian hospital
(with 150 beds) located 80 km away in the west
of the capital and trains local staff while carrying
out daily tests. Tests primarily include microscopy
of malaria and tubercle bacilli. The hospital
plans to conduct bacterial culture. Thus, it
wishes to have a JOCV member experienced in
bacteriological testing.
It is a government-run central hospital equipped
with 850 beds and General Practice, Obstetrics,
Pediatrics, and a TB wing. The JOCV member
works as an administrative pharmacist and looks
into the best usage depending upon the
conditions. Besides, he/she makes proposals and
gives training to local staff. Also, he/she shows
how to take an accurate inventory and estimate
the required quantity of each drug for the proper
purchase of medicines.
The JOCV member is assigned to a
government-run local hospital, with 163 beds,
consisting of General Practice, Obstetrics,
Pediatrics, and a TB wing.
His/her main
activities are akin to those in Japan in general.
They include rehabilitation from hemiplegia
caused by apoplexy or meningitis, broken bones
by traffic accident, infantile paralysis, meningitis,
and burns.
The JOCV member is assigned to a
Health
San Isidro Clinic,
Comarapa Hospital,
Ministry of Health
Male Local Hospital,
Ministry of Health
St. Joseph’s Mission
Hospital, Ministry of
Health
St. Gabriels Mission
Hospital, Ministry of
Health
Malamulo
Mission
Hospital, Ministry of
Health
National
Kasungu
Hospital, Ministry of
Health
National
Lilongwe
2000.10
therapist
Malawi
2000.4 ~
2002.4
Pharmacist
Malawi
2000.4 ~
2002.4
Clinical
laboratory
technologist
Malawi
2000.7 ~
2002.7
Pharmacist
Malawi
2000.7 ~
2002.7
Pharmacist
Malawi
2001.4 ~
2003.4
Physical
therapist
Nepal
2001.7 ~
2003.7
Public health
nurse
Cambodia
2002.4 ~
2003.1
Clinical
laboratory
government-run central hospital, with 850 beds,
consisting of General Practice, Obstetrics,
Pediatrics, and a TB wing.
His/her main
activities are akin to those in Japan in general.
They include rehabilitation from hemiplegia
caused by apoplexy or meningitis, broken bones
by traffic accident, infantile paralysis, meningitis,
and burns.
It is a Christian hospital that has 262 beds and
General
Outpatients,
Pediatrics,
Surgery,
Gynecology, and a TB wing.
The JOCV
member works as a pharmacist and is primarily
responsible for the management of drugs and
inventory control.
It is a Christian hospital that has 262 beds and
General
Outpatients,
Pediatrics,
Surgery,
Gynecology, and a TB wing.
The JOCV
member works as a clinical laboratory
technologist. Basic knowledge and skills of
testing in general are required.
It is a Christian hospital with about 164 beds and
is a medium-sized core hospital in the region.
The wings consist of Men’s, Women’s, TB, and
Pediatrics. The Outpatient Dept. treats all sorts of
patients. The JOCV member is responsible for,
in particular, inventory and the management of
medical supplies.
It is a Christian hospital with about 230 beds
consisting of General Outpatients, Surgery,
Pediatrics,
Gynecology
and
Obstetrics,
Ophthalmology, and a TB wing. The JOCV
member works as a pharmacist. He/she is
chiefly in charge of counter work, inventory
control, and ordering. A computer is used for
the management of medical supplies. Hence,
he/she is required to have the ability to teach the
skills required.
It is a government-owned hospital with 163 beds
that covers the entire area of Kasungu and
consists of Men’s General Practice, Women’s
General Practice, Obstetrics, Pediatrics, and a TB
wing. The JOCV member primarily carries out
rehabilitation from sequelae (or after effects) of
cerebral vascular disorder and spinal cord injury.
It is also important to give training to the hospital
staff.
The JOCV nurse is assigned to the city office of
the city that is 450 km away from the capital.
He/she is responsible for assisting the operation
of six mobile community clinics in the city,
maternal and child health, infectious disease
control including TB, and planning a regional
health program primarily comprising education
and instruction to residents on public health.
It is a general hospital with 415 beds and a staff of
375 (out of which 39 are physicians). In the
Central
Hospital,
Ministry of Health
Muranje
Mission
Hospital, Ministry of
Health
Muranje
Mission
Hospital, Ministry of
Health
Holy Family Mission
Hospital, Ministry of
Health
Nkhoma
Mission
Hospital, Ministry of
Health
Kasungu District
Hospital, Ministry of
Health
Dharan City Office,
Ministry of Local
Development
Laboratory, Svay Por
District Referral
technologist
Dominican
Republic
2003.4 ~
2005.4
Public health
nurse
Botswana
2003.7 ~
2005.7
Nutritionist
Botswana
2004.4 ~
2996.4
Nutritionist
Pakistan
2004.4 ~
2006.4
Public health
nurse
Honduras
2004.7 ~
2006.7
Infectious
disease
control
Honduras
2004.7 ~
2006.7
Infectious
disease
control
laboratory with a staff of ten technicians, the
JOCV member gives advice on manual
procedures of blood tests including blood cell
counts and general urine tests. He/she is also
requested to support the TB control program.
The JOCV member works at the provincial office
in the area of the peninsula 250 km in the
northeastern direction from the capital and offers
cooperation to school health, expansion of
immunization, and TB, dengue fever, and AIDS
control by paying visits to the community and
also by training of extension workers in the
region. He/she becomes involved in the lives
of the residents by and large. Hence, it is
required that he/she has a broad view and a
flexible way of thinking beyond the area of
medicine.
The JOCV member carries out his/her activities as
a dietician at a national primary hospital with 39
beds consisting of General Practice, TB,
Obstetrics, Pediatrics, and a wing for a fee. It is
required that he/she has basic knowledge and
skills as a dietician and is also able to prepare a
variety of nutritionally balanced dishes.
The JOCV member works as a dietician at a
national primary hospital, with 65 beds,
consisting of General Practice, TB, Obstetrics,
Pediatrics, and a wing for a fee. It is required
that he/she has basic knowledge and skills as a
dietician and is able to prepare a variety of
nutritionally balanced dishes.
The JOCV nurse works at the education center
(under the Ministry of Social Welfare) in a TB
hospital (under the jurisdiction of the Ministry of
Health) in Rawalpindi, a neighboring city of the
capital. Patients who visit the hospital must
receive counseling at the center. The JOCV
member gives counseling on drugs and daily life.
The JOCV member is assigned to a city located
300 km from the capital and works as a member
of the district’s NGO. In the residential areas of
African Hondurans in four districts, he/she carries
out educational activities necessary for the control
of AIDS, malaria, TB, and digestive organ
infectious diseases.
He/she also extends
cooperation to enhance the collaborative system
with community health centers.
The JOCV member is assigned to a city located
300 km from the capital and works as a member
of the district’s NGO. In the residential areas of
African Hondurans in four districts, he/she carries
out educational activities necessary for the control
of AIDS, malaria, TB, and digestive organ
infectious diseases.
He/she also extends
cooperation to enhance the collaborative system
with community health centers.
Hospital
Samaná
Provincial
Office, Ministry of
Welfare
Thamaga Primary
Hospital, Basic
Health Bureau,
Ministry of Health
Palapye
Primary
Hospital,
Basic
Health
Bureau,
Ministry of Health
Center for
Tuberculosis
Education, Ministry
of Social Welfare and
Special Education
Black Women’s
Association of
Honduras (NGO)
Black Women’s
Association of
Honduras (NGO)
Pakistan
2004.1 ~
2006.12
Public health
nurse
Colombia
2005.7 ~
2007.7
Clinical
laboratory
technologist
Zambia
2005.1 ~
2007.11
Rural
development
extension
worker
Gabon
2005.1 ~
2007.11
Infectious
disease
control
Gabon
2005.1 ~
2007.11
Public health
nurse
The JOCV nurse becomes involved in activities
for improvements in public health under the local
development project (in health, hygiene,
education, and juveniles) implemented by the
Ministry of Social Welfare. He/she belongs to
the project’s office in a village.
He/she
investigates regional needs and provides
necessary information to residents through
holding workshops (including education on TB
control).
The JOCV member belongs to a hospital that
handles about 830 specimens per day (more than
half being blood tests) and carries out tests on
urine, blood, immunology related, parasites,
tubercle bacilli, HIV serum, biochemistry, and
blood components (for transfusion), thereby
contributing to raising the technical level of local
laboratory technicians.
A broad range of
knowledge and techniques is required rather than
advanced expertise.
The JOCV member is assigned to an NGO that
addresses the issues of occupational training and
nutritional improvement among low-income
residents in Lusaka. He/she formulates policies
on 1) organizational management of the field staff
of the TB control project (volunteer workers) and
2) collection and analysis of information
associated with TB in the region. He/she is
required to have knowledge on public health and
hygiene.
In cooperation with the members of the Infectious
Disease Control Team of the hospital, the JOCV
member carries out the following activities: 1. to
assist factual surveys on infectious diseases such
as malaria, leprosy, TB, rabies, and hepatitis; 2. to
give advice on the planning and assist the
implementation of a preventive and education
program; and 3. to give counseling to residents on
infectious diseases.
In cooperation with the staff of the Institute, the
JOCV member plans and manages the preventive
and educational program concerning infectious
diseases (malaria, AIDS, rabies, leprosy, and TB).
Also, he/she helps organize a campaign for
immunization, grasps the conditions of the
health/hygiene of residents, and gives guidance
on health management.
Local Development
Project, Ministry of
Social Welfare
Hospital San Juan de
Dios,
Provincial
Ministry of Social
Security
AMDA
Zambia
(NGO), Ministry of
Finance and National
Planning
Lambarene
Local
Hospital, Ministry of
Health
Institute of Infectious
and Endemic
Diseases Eradication,
Ministry of Health
Table A 1 – 4: Training courses in the area of TB control
(Group training courses 1963 ~ 2004) Note)
Course
Tuberculosis
Laboratory
Network for
DOTS Expansion
STOP TB Action
Training Course
National
Tuberculosis
Program
Management
Background and objectives
Strategies of the course
Tuberculosis is still the leading
infectious disease throughout the
world. Under the flag of the WHO,
DOTS expansion has been expedited.
However, there are a number of
problems in the quality improvement
and accuracy control of bacteriological
test, which is of overriding importance
to diagnosis of patients and evaluation
of the progress of treatment.
In particular, it is essential to build a
nation-wide tuberculosis laboratory
network for effective DOTS expansion.
This course has been organized
based upon experience obtained from
the earlier course and TB projects
carried out in many countries and also
information
from
international
organizations. Thus, the course aims
to meet global needs in TB control.
(The course has evolved from the
course titled “TB control” established
in 1963.)
The course consists of lectures,
practical training, and study visits.
(1) TB control program and the
roles of the Mycobacterium
tuberculosis test
(2) Present state and problems of
the M. tuberculosis test in TB
control in developing countries
(3) Leadership training method
and teaching method
(4) Evaluation of the laboratory
and accuracy control of sputum
smear microscopy
(5) Laboratory
network
and
management in TB control
(6) Basic technology of the M.
tuberculosis test
(7) Maintenance and operation of
experimental
equipment
including microscopes
(8) Correct
handling
of
experiments and experimental
data
(9) Validation tests
(10) Most advanced technology in
the M. tuberculosis test
The course consists of lectures,
practical training, and study visits.
(1) Basics
of
tuberculosis
(epidemiology, immunology,
bacteriology, statistics, HIV
and TB, management, and
social, economic, and cultural
aspects and hygiene education)
(2) National TB control (control
measures in general, main
components, TB and AIDS,
research activities, and the
WHO module)
(3) Epidemiological inquires
(4) Formulation of action plans
The course consists of lectures,
workshops, and study visits.
(1) To learn the most recent TB
control approach
(2) To
learn
TB
control
improvement methods
(3) To discuss various problems in
the implementation of a TB
The course targets at doctors who are
involved in the TB control program in
developing countries.
It provides
training on recent TB control measures
and aims at the development of human
resources who have the capacity to
promote and develop the TB control
program using the most rational,
realistic, and efficient approach under
the social and economic conditions
faced by their own countries.
(The course has evolved from the
original course titled “Laboratory
works for TB control” established in
1976.)
The course introduces methodology
on the implementation and evaluation
of TB control programs at the national
level to fight tuberculosis in developing
countries.
At the same time, its
objective is to contribute to
strengthening the program of each
country through introducing the TB
No. of
participants
(countries)
242 persons
(55 nations)
830 persons
(72 nations)
404 persons
(68 nations)
control program of each participant’s
country and exchanges of opinions.
(The course has evolved out of the
original course titled “To develop
leaders in TB control (program
management)” established in 1973.)
control program
(4) To raise a common awareness
among participants in TB
control
Note) Including the training courses specially offered
Table a 1 – 5: Training course in TB control (Country-specific training course)
No. of
Name of the course
Name of the project
Infectious disease
Infectious disease control and public
control
health in Peru
Duration of cooperation
participants
1995 – 1996
23 persons
(TB and malaria)
Table 1 – 6: Training course in TB control (Local in-country training course)
Outline of the course
Name of the course
Philippines:
Supplementary
No. of
(Name of the project)
Supplementary
Project
for
Duration of cooperation
participants
1998
26 persons
1999 - 2002
223 persons
TB
Project for TB Control for the
Control in Poor Settlements in the
Poor
Philippines
(Local in-country training)
National TB control project
Supplementary
Project
for
TB
Control in Poor Settlements in the
Philippines
(Local in-country training)
Appendix 2: Basic check items
Cooperation for TB control must follow the same procedures taken in any
cooperation for the area of health and medicine. That is, prior to the selection of an
approach, the first thing to do is to carry out a comprehensive analysis of the
developmental conditions of the target country to explore the problems in the country’s
area of health and to look into its priority sectors.
In particular, TB control is built upon the infrastructure of the public health
system. Hence, what is required is to have information on the public health system
and its organizational chart and also on the degree to which the system functions. It is
comparatively easy to convert data on TB into indicators, which means that there is
greater availability of indicators. At the same time, it is also required to infer the
conditions through indicators in the associated areas of health and medicine such as
maternal and child health.
The following table describes the check items. On how to use the following
indicators, please refer to the knowledge site for presentation because there is a case in
which they have been collected and presented in PowerPoint format prior to the
dispatch of a preparatory evaluation study team.
Basic check items
Check item/indicator
Entire area of health
1
National ten-year
development planning, etc.
2
Administrative structure and
system
3
Financial conditions
4
National policy and strategy
for health and medicine
5
Finances of national health
and medicine
Unit/calculation
method
Remarks
Analyze whether emphasis is placed upon
the area of health and medicine or on which
sector of health emphasis is placed from
relationships with national strategies.
Check the wage system of public officials
and PRSP and also confirm whether the
country has introduced the common basket.
Check the degree of decentralization and
the division of roles between the central
government and local governments.
Proportion of expenditure spent in the area
of health
Confirm the presence/absence of national
policy on health and medicine for the
following three to ten years and confirm
how the areas of infectious disease control
and TB control are delineated. In many
countries, it is often the case that issues are
merely inclusively listed. Hence, confirm
whether these areas are clearly defined.
Confirm the budgetary ratio appropriated to
the area of tuberculosis.
National health
administrative structure and
organizations
Achievements and trends of
7
cooperation from other
donors
System of health administration
8
The number of health and
medical institutions by the
referral system
9
Personnel placement
planning and actual
placement
10
Ratio of personnel expenses
in expenditure for health
11
Presence/absence
of
a
medical health system
Outline of the area of tuberculosis
(1) Indicators to show burden
12
Incidence rate
Same as the above 2.
6
Prevalence rate
(2) Indicators to show progress
14
Case detection rate
15
Cure rate
16
DOTS coverage
DOTS population coverage
Percentage of population
covered by DOTS
State of the public health system
17
Infantile mortality
18
Mortality of children under
the age of five
In particular, the WHO, GFATM, KNCV,
and USAID
Standards of establishment such as the
number, population, and area
Medical workers allocated to each
institution by type of occupation and
number
Ratio per 100,000
population of the
estimated number of
new TB patients per
year
Ratio per 100,00
population of the
number of
symptomatic TB
patients at a given
time
They are computed every five years from
the national prevalence survey carried out
by the WHO in earlier years in the country
in question.
They are projected on each category of
smear-positive pulmonary TB and all forms
of TB (smear-positive pulmonary TB,
smear-negative pulmonary TB, and
extrapulmonary TB).
It indicates the
number of TB
patients detected out
of the estimated
number of TB
patients in one
country.
It indicates the
number of TB
patients who have
successfully
completed the 6~8
month regimen.
It indicates the
percentage of
population that has
access to DOTS
services.
Confirm ① case-finding rate, ② progress
of cure rate, and ③ DOTS coverage
towards attaining a case detection rate of
70% and a cure rate of 85%.
Mortality of babies
aged less than one
year old/No. of
births x 1,000
Death rate of
children aged less
19
Mortality
women
20
Main causes of death
Top ten causes of death
21
Causes of death related to
infectious diseases
Average life expectancy at
birth
Percentage of deliveries
attended by a medical
professional
Delivery rate at the medical
institution
Percentage of participation
in pre- and post-delivery
medical checkups
Top five causes of death
22
23
24
25
26
27
28
of
pregnant
than 5 years old/No.
of births x 1,000
Death rate of
pregnant women/No.
of births x 1,000
The number is used to assess the degree of
penetration of the public health system.
The number is used to assess the degree of
penetration of the public health system.
The recommended number of participations
varies by each country. Use the number of
the country in question. The ratio is used
to confirm the degree of penetration of the
public health system.
Mean annual population
growth rate
Total population/population
growth rate
Proportion
of
urban
population
29
Literacy rate among adults
30
Rate of enrollment
primary education
in
Literate adults aged
15 or over/
population of people
aged 15 or over
Number of children
enrolled in primary
education/population
of primary schoolaged children
Calculate the percentage of urban
population out of the total population of
each country.
The percentage of people aged 15 or older
who are able to read and write simple
sentences used in everyday life while
understanding the meaning.