Tuberculosis (TB) remains one of the major public health problems in Nepal. In the Fiscal Year 2017/2018, there were 32,474 TB cases notified in the country. However, the World Health Organisation's Global Tuberculosis Report 2018, suggests that there are 45,000 estimated cases of TB in the country, indicating that there about 13,000 new cases are missed every year. Moreover, the findings from the recent TB prevalence survey will show the estimated TB cases to be much higher than what is being expected now, thus further increasing the gap between estimated cases and notified cases. Further, according to the National Tuberculosis Program (NTP), it is estimated that 123 new TB cases occur in Nepal out of which 34 TB cases are missed daily.
The unprecedented growth of the urban population, including the urban poor, has increased the concentration of at-risk populations in Nepal in urban settings, specifically in the Kathmandu Valley and several urban areas of Terai districts. Among the registered TB cases 24 percent were reported from Province 3 of which 10 percent were from Kathmandu district only. Observing the case distribution by eco-terrain, the Terai belt reported more than half of TB cases (57 percent). Moreover, extended urbanization has resulted in an increased presence of the private sector. Various studies have shown that 60-80 percent of patients approach a pharmacy as the first point of care (still > 46% in the poorest quintile); while 80 percent of the pharmacies are seeing presumptive TB patients. Although there is no specific data available for actual estimates of TB cases being treated in the private sectors in Nepal, it is estimated that 5,000 cases are being circulated in the huge private sectors mostly in the urban settings. Therefore, there is a significant scope to build linkages with unengaged private care providers across the country and strengthen the collaboration of private care providers with the NTP.
Presumptive TB patients when visiting non-governmental providers unengaged with NTP undergo a variety of unnecessary diagnostic tests, spend enormous time before getting the right diagnosis and anti-TB treatment. If the presumptive TB patient approaches a non-government provider engaged with NTP, the patient undergoes a free sputum microscopy test and if diagnosed with TB will be provided with free anti-TB drugs. To support this initiative, National Strategic Plan 2016-2021 envisions harnessing PPM as outlined under objective 4: “To expand case finding by engaging providers for TB care from the public sector (beyond MoH), medical colleges, NGO sector, and private sector through results-based financing (PPM) schemes, with formal engagements (signed MoUs) to notify TB cases”. However, due to the lack of proper funding, the PPM intervention is yet to be implemented.
Considering this situation, Nepal CRS Company has recently entered into an agreement with Save the Children US/The Global Fund Tuberculosis Program. The 15-month project started in September 2019. The project focuses on six urban districts: Kathmandu, Lalitpur, Parsa, Morang, Banke, and Chitwan. The project aims to expand case findings by engaging providers for TB care from medical colleges, private sectors (Pharmacies, Private practitioners and Private hospitals) and Urban Volunteers through various contextualized interventions including results-based financing schemes, to promote early case findings, adequate referral and case diagnosis, early initiation of TB treatment and reduction in drug resistance and ultimately reducing catastrophic cost related to TB for the families affected by it.
The major goal of the project is to increase the case notification of the Tuberculosis cases from the private sector. The objectives of the project are:
The major stakeholders include pharmacies, hospitals, private practitioners and the urban volunteers. Apart from them, other concerned stakeholders include NTCC, Provincial health directorate, and TB focal persons, Mayors, chief of health offices and health coordinators.
The project activities can be categorized as:
The project establishes a patient-referral mechanism from pharmacies and links them for TB detection. The project also aims to identify presumptive cases and refer them to the appropriate site as soon as possible by linking pharmacies to ultimately increase case notification.
Similar to the above activity, the project links urban volunteers and establishes referral mechanisms from them so that presumptive TB cases from the community can also be linked and treated promptly.
Here the project links hospitals for FAST strategy and looks for presumptive TB cases. First, we screen for presumptive TB cases, separate them and then provide them with appropriate and prompt treatment. Apart from screening for passive cases, Outreach Workers (OWs) will also look for referred cases by pharmacies and urban volunteers so that they can be screened and provided with prompt treatment.
Similarly, the project engages the private practitioners that are outside of NTP but are treating TB patients through their clinics or hospitals, so that we can identify the missing cases and bring them into our national reporting system.