Implementing a successful tuberculosis programme within primary care services in a conflict area using the stop TB strategy: Afghanistan case study

Conflict and Health

Wasiq M Khan⁴  Zaeem Haq⁵  Karam Shah³  Donald A Enarson¹  Khaled Seddiq² 

[1] International Union against Tuberculosis and Lung Disease, Paris, France;National TB Control Programme, Darul-aman, Kabul, Afghanistan;Stop-TB, Kabul, Afghanistan;WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt;Health Services Academy, Islamabad, Pakistan

关键词: Sustainability;    Implementation;    Tuberculosis;    Conflict;    Afghanistan;   

Others  :  803416
DOI  :  10.1186/1752-1505-8-3

 received in 2013-05-22, accepted in 2014-02-06,  发布年份 2014

【 摘 要 】

Introduction

Afghanistan has faced health consequences of war including those due to displacement of populations, breakdown of health and social services, and increased risks of disease transmission for over three decades. Yet it was able to restructure its National Tuberculosis Control Programme (NTP), integrate tuberculosis treatment into primary health care and achieve most of its targets by the year 2011. What were the processes that enabled the programme to achieve its targets? More importantly, what were the underpinning factors that made this success possible? We addressed these important questions through a case study.

Case description

We adopted a processes and outcomes framework for this study, which began with examining the change in key programme indicators, followed by backwards tracing of the processes and underlying factors, responsible for this change. Methods included review of the published and grey literature along with in-depth interviews of 15 key informants involved with the care of tuberculosis patients in Afghanistan.

Discussion and evaluation

TB incidence and mortality per 100,000 decreased from 325 and 92 to 189 and 39 respectively, while case notification and treatment success improved during the decade under study. Efficient programme structures were enabled through high political commitment from the Government, strong leadership from the programme, effective partnership and coordination among stakeholders, and adequate technical and financial support from the development partners.

Conclusions

The NTP Afghanistan is an example that public health programmes can be effectively implemented in fragile states. High political commitment and strong local leadership are essential factors for such programmes. To ensure long-term effectiveness of the NTP, the international support should be withdrawn in a phased manner, coupled with a sequential increase in resources allocated to the NTP by the Government of Afghanistan.

【 授权许可】

   
2014 Seddiq et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Murray CJL, King G, Lopez AD, Tomijima N, Krug EG: Armed conflict as a public health problem. Br Med J 2002, 324:346-349.
• [2]Gele A, Bjune G: Armed conflicts have an impact on the spread of tuberculosis: the case of the Somali Regional State of Ethiopia. Confl Health 2010, 4:1. BioMed Central Full Text
• [3]Waters H, Garrett B, Burnham G: Rehabilitating health systems in post-conflict situations. Helsinki: UNU World Inst. for Development Economics Research (UNU/WIDER); 2007.
• [4]Ohiorhenuan JF, Stewart F: Crisis Prevention and Recovery Report 2008: Post-conflict Economic Recovery, Enabling Local Ingenuity. New York: United Nations Development library; 2009.
• [5]Collier PHA: Greed and grievance in civil war. Oxf Econ Pap 2004, 56:563-595.
• [6]Ministry of Public Health: Tuberculosis Control in Afghanistan: Annual Report. Kabul: Ministry of Public Health; 2010. Ref Type: Report
• [7]Sharp TW, Burkle FM, Vaughn AF, Chotani R, Brennan RJ: Challenges and opportunities for humanitarian relief in Afghanistan. Clin Infect Dis 2002, 34:S215-S228.
• [8]World Health Organization: Global Tuberculosis Control: WHO Report 2001. WHO/CDS/TB/2001.287. 2001. Geneva, Switzerland: World Health Organization; 2011. Ref Type: Report
• [9]Ahmadzai H, Kakar F, Rashidi M, Suarez PG, Ameli O, Hartman AF: Scaling up TB DOTS in a fragile state: post-conflict Afghanistan. Int J Tuberc Lung Dis 2008, 12:180-185.
• [10]Mauch V, Weil D, Munim A, Boillot F, Coninx R, Huseynova S, et al.: Structure and management of tuberculosis control programs in fragile states Afghanistan, DR Congo, Haiti, Somalia. Health Policy 2010, 96:118-127.
• [11]World Health Organization: Global Tuberculosis Control 2012. Geneva: World Health Organization; 2012. Ref Type: Online Source
• [12]World Health Organization: Global Tuberculosis Control 2011. Geneva: World Health Organization; 2011. Ref Type: Report
• [13]Bartlett LA, Mawji S, Whitehead S, Crouse C, Dalil S, Ionete D, et al.: Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999−2002. Lancet 2005, 365:864-870.
• [14]Patton MQ: Qualitative Research & Evaluation Methods. 3rd edition. California: Sage Publications; 2002.
• [15]Glesne C: Becoming Qualitative Researchers: An Introduction. 4th edition. Boston: Pearson Education, Inc.; 2011.
• [16]Maxwell J: Qualitative Research Design: An Interactive Approach. 2nd edition. Thousand Oaks: Sage Publications; 2005.
• [17]National TB Control Programme: Tuberculosis Control in Afghanistan: Annual Report. Kabul: Ministry of Public Health, Islamic Republic of Afghanistan; 2013. Ref Type: Report
• [18]National TB Control Programme: Tuberculosis Control in Afghanistan: Annual Report. Kabul: Ministry of Public Health, Islamic Republic of Afghanistan; 2010. Ref Type: Report
• [19]Saeed KMI, Bano R, Asghar RJ: Evaluation of the national tuberculosis surveillance system in Afghanistan. EMHJ 2013, 19:200-207.
• [20]Khan IM, Laaser U: Burden of tuberculosis in Afghanistan: update on a war-stricken country. Croat Med J 2002, 43:245-247.
• [21]Gilson L: Trust in health care: theoretical perspectives and research needs. J Health Organ Manag 2006, 20:359-375.
• [22]Kruk ME, Freedman LP, Anglin GA, Waldman RJ: Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda. Soc Sci Med 2010, 70:89-97.
• [23]Doveren RFC: Why tuberculosis control in an unstable country is essential: desperate TB patients embrace DOTS in Angola [Notes from the Field]. Int J Tuberc Lung Dis 2001, 5:486-488.
• [24]Percival V, Sondorp E: A case study of health sector reform in Kosovo. Confl Health 2010, 4:7. BioMed Central Full Text
• [25]Lainez YB, Todd CS, Ahmadzai A, Doocy SC, Burnham G: Prevalence of respiratory symptoms and cases suspicious for tuberculosis among public health clinic patients in Afghanistan: Perspectives on recognition and referral of tuberculosis cases. Trop Med Int Health 2009, 14:564-570.
• [26]Sabawoon W, Sato H, Kobayashi Y: Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan. Environ Health Prev Med 2012, 17:53-61.
• [27]Cegielski JP, McMurray DN: The relationship between malnutrition and tuberculosis: evidence from studies in humans and experimental animals. Int J Tuberc Lung Dis 2004, 8:286-298.
• [28]Zachariah R, Spielmann MP, Harries AD, Salaniponi FML: Moderate to severe malnutrition in patients with tuberculosis is a risk factor associated with early death. Trans R Soc Trop Med Hyg 2002, 96:291-294.
• [29]Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G: A balanced scorecard for health services in Afghanistan. Bull World Health Organ 2007, 85:146-151.
• [30]Waldman R, Strong L, Wali A: Afghanistan's Health System Since 2001-Condition Improved, Prognosis Cautiously Optimistic. Kabul: Afghanistan Research and Evaluation Unit; 2009. Ref Type: Online Source
• [31]Canavan A, Vergeer P, Bornemisza O, Hughes J: Post-Conflict Health Sectors: The Myth and Reality of Transitional Funding Gaps. Amsterdam: Royal tropical institute (KIT); 2008.