Global Funding and DOTS Coverage Vital for Mobilizing TB Programmes


By Miriam Fisher, Womens Feature Service

About 10 months ago, Anu Marhatta, 19, had a bout of fever along with a cough. Two months later it was clear that Anu had developed Multi Drug Resistant Tuberculosis (MDR-TB). It turned her happy world upside down.

Nepal gets 48,766 new cases of active TB every year. Fortunately it has one of the best run TB programmes in South Asia. There’s 100 per cent national DOTS (Directly Observed Treatment Short course) coverage. All systems and counselling services are working well. And with Nepal becoming the first country in 2006 to adopt WHO’s Stop TB, initiatives to manage the new challenges in the treatment of the disease have been initiated with the help of the Global Fund.

Anu Marhatta, who lives in Balaju, would have loved to attend her college classes, but a dry, persistent cough came in the way. “About 10 months ago I had a bout of fever along with a cough. The doctor put me on antibiotics for a month,” she recalls. After about four months her sputum test for tuberculosis proved positive. She was put on stronger medication. Two months later, it was clear that Anu had developed Multi Drug Resistant Tuberculosis (MDR-TB).

The 19-year-old feels very isolated. She is not sure whether her friends know that she has MDR-TB. The picnics and movies of earlier times are now a distant memory. Her medications caused intense nausea, but now she is used to it. She has gained weight though which is a good thing. She weighs 38 kilos before and now she weighs 42 kilos.

According to Dr. Kashi Kant Jha, who heads the National Tuberculosis Centre (NTC) that coordinates TB diagnosis and management for the country, successful mobilization of TB programmes are due to two relevant factors. One, the priority was given to the National Tuberculosis Programme (NTP) by the Ministry of Health & Population. The country started its DOTS programme in 1996. Since then, it has been able to achieve 100 per cent national coverage. Two, technical support from World Health Organization (WHO) and financial support from Global Fund.

The institution over which Dr. Jha presides, the NTC, was located in Thimi, Bhaktapur, on the outskirts of Kathmandu Valley. It is a beehive of activity. It sees around 60-70 patients a day in its outpatients department. Among the NTC’s key functions is the development of NTP policies, strategies and plans, apart from research generation.

In 1995, the WHO recommended the DOTS strategy. It relied on the simple notion of health workers directly observing patients taking their medication. Nepal took this up immediately, launching it in four districts. It was one of the first countries in South-East Asia to implement the initiative. By 2000, DOTS was being used nationwide. In 2006, Nepal became the first country to adopt WHO’s Stop TB, a six-pronged strategy that included pursuing high-quality DOTS expansion. It envisaged the strengthening of the health system, engaging with all care providers and promoting further research.

Today, DOTS is available in over 4,000 sites across Nepal, with 427 established microscopic labs providing facilities for diagnosis. Besides this, there are 54 sub-centres and 12 treatment centres providing MDR-TB treatment services specifically. Thanks to this pro-active approach, Nepal has achieved global targets for TB control. In 2009, treatment success exceeded 90 per cent.

In 2010, WHO reported that among all TB cases globally, 3.6 per cent are estimated to have MDR-TB. While in certain parts of the world, this could even be as high as 28 per cent of all new TB cases. MDR-TB is defined as a particularly dangerous strain of tuberculosis that does not respond to standard first-line drugs.

What has helped address the stigma associated with MDR-TB is the fact that Nepal has no policy to hospitalise MDR-TB positive patients. Ideally, given that TB is an air-borne disease, isolation of the patient is advisable. But because there are just not enough beds available, the country has opted to run its TB programme through its TB centres delivering daily supervision.

Financial support from Global Fund has helped keep these centres running and expand the TB programme. The fund has recently quadrupled its contribution, committing USD 56 million for the next five years up to mid-2015.

Funding is just one aspect of a complex programme that has to deal with experiences of ordinary people. This is where community participation and awareness can play an immensely rewarding role. One of the unique features of the Nepal TB programme, according to Dr Akhtar, is the DOTS committees throughout Nepal. “With funding now available, these committees at the Village Development Committee level – the lowest tier – can be re-invigorated,” he hopes.