turkey tb programme review
DESCRIPTION
Turkey TB Programme Review. 26 March to 6 April 2006. Review mission. 7 teams 10 international and 15 national team members Provinces visited AnkaraIstanbul Bur s a Duzce Er z urum Trabzon Rize Diyarbakir Mardin. Places visited. Constraints and challenges. - PowerPoint PPT PresentationTRANSCRIPT
Turkey TB Programme Review
26 March to 6 April 2006
Review mission
7 teams
10 international and 15 national team members
Provinces visited
Ankara Istanbul Bursa
Duzce Erzurum Trabzon
Rize Diyarbakir Mardin
Places visited NTP, MoH, MoJ, Ankara School of Public Health
7 Provincial and district health directorates
10 Primary health care facilities
20 TB Dispensaries 1 Chamber of Pharmacy
8 Chest Disease hospitals 1 Municipality
5 Teaching hospitals 1 Military hospital
4 Regional laboratories 2 TB Association
10 TB dispensary laboratories 4 Mobile TB Control Teams
4 University laboratories 6 Pharmacies
1 Center for HIV/AIDS 84 Total places
Constraints and challenges DOTS expansion has been slow
Central political commitment not always translated into effective functioning TB programme at provincial and district levels (some provinces lack TB coordinators)
The Central TB unit has limited stewardship capacity
Regular supervision is not performed and there is not available budget to support it
No available specific data on HR for TB control, distribution and skill mix is inadequate in some provinces
Discontent with the revolving fund (bonus system) which is unfair with TB control staff
Constraints and challenges Health system transformation and integration with PHC
offer opportunities to TB control but integration without adequate stewardship and training capacity will be detrimental
Sputum microscopy is not routinely used for diagnosis and treatment monitoring
The Ankara Central Hifzıssihha Reference Laboratory is not officially designated by the MoH as the National Reference Laboratory
Several laboratories perform sputum microscopy, culture and DST without adequate bio-safety and QA programme
Constraints and challenges Too many patients are unnecessarily hospitalized during
initiation of treatment
No adequate referral system between TB dispensaries and hospitals, and poor or not existent integration with primary care
Management of TB in children is not standardized
Fixed dose combinations are not available
All anti-TB drugs can be obtained without prescription
No standardized approach and guidelines on contact tracing and some practices are not justified
Constraints and challenges Numerous groups are screened unnecessarily
Recording and reporting forms were introduced without
adequate training and are erratically used
There is no systematic reporting from hospitals and no
system for laboratory reporting of confirmed cases
No nationwide data on MDR-TB
No guidelines for management of MDR-TB and self
administration of treatment during continuation phase
Constraints and challenges Poor collaboration between TB and HIV/AIDS
programmes
PPM not properly address, no coordination, guidelines or defined TOR
Lack of understanding on advocacy and the role of empowered communities on TB control
Basic operational research is not commonly done
No TB coordinator at the Istanbul Provincial Health directorate
Insufficient HR capacity at TB dispensaries and laboratories
Planned rapid scale up of DOTS without proper planning
RecommendationsPolitical commitment and DOTS
Expansion1. Sustain and enhance Political commitment to TB control
2. Expand the TB Scientific Committee to include representation of all stakeholders
3. Elaborate a 5 year strategic plan for DOTS expansion and endorse it by the MoH. The Annual DOTS implementation plan should be updated yearly
a. Review and update Guidelines for all aspects of TB diagnosis, treatment and control
4. Elaborate and implement system for routine programme monitoring, supervision and evaluation
5. Include dedicated funds for training, monitoring, supervision and programme evaluation in the MoH budget for TB control
RecommendationsHuman Resources6. Assess existing human resources, including laboratory, to
ensure adequate number of trained staff are available at all levels. a. Elaborate a HR development plan according to the identified
needs
b. Re-define roles and responsibilities, include in job descriptions and ensure appropriate training
c. Appoint training coordinators at central and provincial levels to assess training needs, develop materials and ensure regular, coordinated and standardized training
7. Define the role of primary health care staff in TB control and provide training and empowerment
8. Revise the Revolving Fund to appropriately reward health workers in all levels of TB care and control
RecommendationsHealth System Transformation 9.Ensure NTP technical and stewardship capacity to provide
necessary knowledge and skills to PHC. Regular training, supervision, M/E are important.a.Re-evaluate and re-organize the functional structure of the NTP.
Review the skill-mix at the Central Unit in order to provide oversight and stewardship to the provinces and play the leading role in TB Control
b.Establish the position of provincial TB coordinator and ensure official recognition
c.Maintain TB dispensaries, re-define their role in view of the planned integration with PHC and empower them to coordinate TB control locally
d.Mobile TB Control Groups should be preserved and re-evaluate
their organization, roles and responsibilities in PHC integration
RecommendationsDiagnosis
10.Recommend and implement nationwide use of smear microscopy for diagnosis and treatment monitoring
a.Establish a laboratory network and ensure regular QA
through QA programme. Implement bio-safety in all
laboratories.
b.Officially designate the reference laboratory in Ankara as
the National Reference Laboratory with clear TOR.
c.Rationalize the number of laboratories performing
microscopy, culture and DST according to local needs and
workload.
Recommendations
Treatment11.Treatment in hospitals should always be administered
under D.O. Organize D.O.T. in TB dispensaries in
collaboration with PHC and other providers.
12.Number of hospitalized TB patients should decrease
with PHC integration and follow indications for
hospitalization.
13.Paediatric TB cases should be treated according to
existing guidelines and reported to the NTP. BCG
vaccination at birth should be maintained and performed
by PHC.
RecommendationsDrug supply
14.Maintain the system for centralized drug procurement.
All TB drugs, including second line drugs, should be
provided free of charge to all patients.
a. Ideally, TB drugs should only be available through
the TB programme.
b.Fixed Dose Combinations (FDC) of demonstrated
bioavailability should be used, especially in the
absence of direct observation of treatment.
Recommendations
Contact tracing and screening
15.Guidelines for contact tracing and preventive
chemotherapy should be updated.
16.The TB screening programme should be re-defined in
order to target actual risk groups for TB.
RecommendationsRecording and reporting17.It is not recommended to drastically change recording
and reporting forms in near future a) Training should be done on their proper use.
b) Simplify them as possible.
c) Each reporting unit (including all hospitals) should appoint a person responsible for TB registration and reporting.
d) Hospitals should be encouraged to use at least the TB patient register.
e) TB dispensaries should include all patients from prisons in the TB patient register.
18.Electronic individual case reporting should be implemented.
Recommendations
Drug resistance and MDR-TB
19.A nation-wide drug resistance survey should be planned and performed.
20.National guidelines for management of MDR-TB should be developed, endorsed, disseminated and implemented.
Recommendations
TB/HIV21.A collaborative framework for TB and HIV/AIDS
programmes should be developed.
Public-Private DOTS22.An agreed policy defining roles of all stakeholders
in TB control should be developed.
Recommendations
Istanbul
23.Istanbul's unique TB situation should be specifically
addressed in the National Strategic Plan.
a. Establish a TB Advisory Committee consisting of all
stakeholders to advise and assist the Provincial Health
Directorate in developing a plan for DOTS expansion
b. Implementation of the Istanbul DOTS Expansion Plan
should be monitored periodically by the MOH.
Update
Improvement of TB Surveillance – training done in TB Surveillance in March 2007 with WHO EURO financial and technical support
Strengthening the laboratory network- mission of head of SNL Daniela Cirrillo later in May 2007 in Turkey
Support offered to NTP staff member of participating in TB/HIV training in Sondalo, summer 2006
The report is in for editing and then will be placed on the WHO EURO web page