The National Tuberculosis Control Program (NTCP) Pakistan aims at reducing the burden of tuberculosis through improved patient education and care. The program includes cluster meetings, PMDT, and compliance. In 2011 the number of cases per 100,000 was 59. In Sindh, the CNR for all types of cases was 135 and the CNR for NSS1 + 2 cases was 59. The NTP carries out its work under the supervision of the provincial government of Pakistan.
Cluster meetings
The National Tuberculosis Control Program (NTCP) in Pakistan has been monitoring the progress of disease control activities through cluster meetings. The meetings are held every three to four months at diagnostic facilities. They are led by a District TB Coordinator and involve TB Facilitators, who are paid fixed travel costs of US$3.5 each. The meetings also include a progress review and a diagnostic centre’s action plan.
The TB Control Program has three main goals: a TB-free Pakistan by 2025, universal access to quality TB care, and Zero TB deaths. Currently, Pakistan is the fifth highest burden country in the world, with a prevalence of 348 cases per 100,000 people. The mortality rate is 34 per 100,000.
In the study, the NTP identified ten study districts in each of Pakistan’s four provinces. The selection criteria were based on geographical distribution, functioning adult TB care, and willingness to participate in the study. The Punjab Province was select because it has a consistent programme support and a strong support network in the province, as well as provision of tuberculin skin test and anti-TB drugs for children. The data collected from the study districts were collected from hospital TB records.
In the study, the effectiveness of the structured monitoring process was evaluated. The study area involved eight districts with intervention and eight control groups. Managers of the two groups used tools for monitoring meetings and performance monitoring guidelines to monitor TB case management practices. The ratio of suspect outpatients, number of registered cases, and patient default rate were monitored. In addition to this, participants’ experiences were evaluated through semi-structured interviews.
Patient education
Patient education is a vital component of a successful TB control program. However, poor patient education can cause complications in treatment and may hinder adherence. Lack of health literacy and education about treatment options may also increase the risk of drug resistance. The impact of patient education on TB control will analyze through a number of studies.
In 2005, Pakistan implemented a five-year plan to achieve universal coverage of DOTS in the public sector by the end of 2005. The federal Ministry of Health and the provincial Departments of Health lined up funding and integrated TB control activities into the primary health care system. Although progress has been made, challenges remain. These include poor human resources, suboptimal quality of service in public health outlets, and low government commitment.
The National TB Control Program Pakistan (NTCP) has developed a training programme for national health workers and trained them to deliver quality TB care. The National Tuberculosis Control Program and PTPs have partnered with the WHO to coordinate their technical assistance. The two organizations will conduct joint programme reviews every year.
This new paradigm of engagement between the NTP and primary health centres has the potential to strengthen the district health system by integrating primary health center services into NTP. The two groups also have the same goal: to increase TB case detection.
Compliance
A significant component of the National Tuberculosis Control Program (NTCP) in Pakistan is compliance with the treatment regimens, prescribed by the NTP. Non-compliance is often a significant barrier to eliminating tuberculosis. Poor adherence to treatment regimens commonly associates with the lack of educational programs and poor communication between healthcare providers and patients.
The government of Pakistan has enlisted the support of development partners to achieve the goal of TB control in the country. A 5-year plan was formulate and implement, leading to universal coverage of DOTS (Direct Occupational Therapy for TB) in the public sector by 2005. The federal Ministry of Health and provincial Departments of Health coordinated the funding, integrating TB control activities into the primary healthcare system. However, the implementation of DOTS faced a number of challenges. These included limited human resources, substandard quality of services at public health outlets, and lack of commitment from peripheral level authorities.
Despite the NTP’s efforts, the country has not yet reached the first goal of zero new cases. The prevalence of TB in Pakistan is currently higher than the world average, at 3%. A survey conducted in 1962 was the first step towards achieving this goal. The government has allocated funding to each province’s NTP. Once the first objective reaches, the target for new cases will increase to 70%. In addition, the NTP focuses on promoting early diagnosis of pulmonary TB.
Although the National Tuberculosis Control Program has seen a dramatic expansion in TB care in the last decade, the number of cases has increased from 11 050 cases in 2000 to 248 115 in 2008. As of 2008, over one million TB patients have treated and the treatment success rate was 91%. The NTP also engages private practitioners, laboratories, and hospitals to deliver key TB interventions.
COVID-19 control in Pakistan
During the localise smart lockdown in Pakistan, many outpatient departments were shut down. The result was a significant reduction in drug-susceptible TB cases. By April 2020, the number of drug-resistant TB cases was down by 35% and drug-susceptible TB cases were down by 45%. The case study highlights the importance of addressing stigma and implementing effective strategies.
The Zero TB Karachi team was able to work at pre-pandemic sites, which contributed to almost 80% of the city’s case notifications. They were able to adapt real-time to ensure that TB services were provided to patients, while also diagnosing patients with COVID-19.
The sustainability of newly-implemented interventions depends on shared understanding among stakeholders. Although government of Pakistan considers the primary stakeholder, the involvement of other functionaries and nongovernmental organizations is also critical. These organizations include local community organizations, faith-based organizations, and professional associations. The study also notes that inadequate funding is a key challenge to sustainability.
Developing a comprehensive public health response to COVID-19 is essential, and combining efforts from different sectors will maximize the impact of the program. Public education should strengthened in high-risk areas, while a multi-sectoral approach should address social determinants of health.
TB incidence in Pakistan
The national TB prevalence survey carried out in 2010-2011 revealed an overall prevalence of TB of 270.3 cases per 100,000 population. This is higher than the previous survey carried out between 1987 and 1989, which reported a prevalence of 170 cases per 100,000 population. The survey also found that the prevalence of TB was 1.5 times higher in men than in women, and that the incidence of the disease increased with age. TB incidence was highest in the province of Sindh.
The National Sample Survey (NSS) 1 + 2 cases in Sindh were 59 cases per 100,000 in 2011. The CNR for all types of cases was 135 in the province. The NTP carried out this study under the supervision of the provincial government of Pakistan. The findings of the study have important implications for TB control in Pakistan. There is a need to improve the TB program in the rural areas to reduce the incidence of this disease.
Although TB is a widespread disease in Pakistan, its incidence is still low, partly because the population is ill-inform and unaware of the symptoms. The study found that a small percentage of the population had knowledge of the disease and knew how to recognize symptoms. For example, a cough lasting more than three weeks is a sign of pulmonary TB.
