March 21, 2008 -- When 45-year-old Rene Djoko checked into the Jamot Hospital, the premier referral facility for complicated TB cases in Yaounde, Cameroon, he was weak, had a persistent cough, and was unable to work. After four months of TB treatment, Djoko is on the way to recovery.
In Cameroon, as in other countries, years of neglect are reflected in the physical appearance of the hospitals. But, says Djoko, the care here is “impeccable.”
Others like Djoko, who suffer from TB and other diseases, travel hours from Douala because the “drugs are better here,” highlighting positive perceptions about the quality of care. What the hospital lacks in terms of work environment it makes up for in staff dedication.
Globally, one person dies of TB every 20 seconds, even though drugs to cure the disease have been available for 50 years and cost only $25 per person. Over the past two decades, sub-Saharan Africa has seen a resurgence of this airborne disease, which disproportionately affects the poor. In Africa, TB is the leading killer of people living with HIV/AIDS.
In Southern Africa, weak TB control combined with a spiraling HIV epidemic has resulted in multi-drug resistant TB which dramatically increases treatment costs, duration of treatment, and lowers chances of treatment success.
“Multi-drug resistance in Southern Africa is becoming an increasing threat to the hard-won health and development gains in the region,” said World Bank Group President, Robert Zoellick. “Given the stakes involved, we need to step up our efforts in concert with our African partners, as part of our drive to strengthen health care systems.”
“The WHO 2008 Report on Global TB Control finds that the pace of progress to control the TB epidemic is slowing, and there is urgent need to accelerate scale-up in Africa,” said Dr. Mario Raviglione, director of the WHO Stop TB Program. “The Bank can leverage the momentum to make this possible in Africa."
Weak Health Systems
Individuals co-infected with TB/HIV in Africa have to navigate weak health systems and jump through numerous hurdles in order to get care. Many shuffle between health clinics for TB medications and district hospitals for antiretroviral drugs. HIV providers are often not comfortable treating TB patients and TB specialists are not always up to date on HIV care. While services and drugs are generally free or highly subsidized, patients complain about the cost of lab exams, hospitalization, and transportation.
As World Bank President Robert B. Zoellick learned during a recent visit to Mozambique, patients are often too sick to travel long distances to first-line health facilities which prevents them from getting an early diagnosis of TB. In Kenya, as well, “the greatest challenge in TB control is changing the health seeking behavior of Kenyans [and] urging them to seek care early before complications develop,” according to Dr. Joseph Sitienei, manager of Kenya’s national TB program. Sitienei credits the country’s accomplishments to front line providers who work under difficult conditions.
Across Africa, stigma persists and leads some to seek care from traditional healers who promise rapid cure. In Rwanda, 30-year-old Justin Barayavuze, a father of two young children, found out about his HIV status when he accompanied his HIV-positive, pregnant wife for antenatal care and was urged to be tested. In addition to TB treatment, Barayavuze was placed on antiretroviral therapy at the Bank-supported Mibilizi Hospital. His weight had dropped to barely 84 pounds, he suffered from anemia, and his immune system was seriously compromised. After five months of treatment for both diseases he began to regain his strength.
Patients like Barayavuze often seek care at an advanced stage of the disease which increases the risk of infecting others, and makes treatment more complicated and more costly.
Kenya, Malawi, and Rwanda, among other countries, have established integrated HIV/TB services, offering HIV testing and counseling, TB diagnosis, and treatment for co-infected individuals.
Dr. Michel Gasana, director of the Rwanda’s TB Control Program, says the country’s “one stop service” approach centered on patients is a key feature of the program. The country has revamped the way services are organized and financed. An opt-out policy (whereby TB patients are routinely tested unless they refuse) resulted in more than 76 percent of TB patients being tested for HIV in 2006.
Under a performance-based contracting approach for HIV/TB services in the Rwanda HIV/AIDS Project, bonus payments are made to teams of providers based on results attained. This scheme has stimulated such innovative strategies as TB case-finding by community workers and home visits to co-infected patients. Providers are encouraged to take a holistic approach to care, including promotion of institutional deliveries for pregnant women, and family planning. Systematic supervision by district officials, which is also remunerated, provides an opportunity to give feedback to staff.
Dr. Agnes Binagwaho, Executive Secretary of the Rwanda HIV/AIDS commission, notes the tremendous potential of people living with HIV/AIDS to raise awareness and promote behavior change at the community level. She also points out that the country has given a major impetus to integration across the three major diseases (TB, HIV/AIDS and malaria).
Attacking these diseases in a joint effort is part of the World Bank’s plan.
“In countries across Africa that are struggling with the co-epidemic, one cannot mention HIV without mentioning TB and vice versa,” said Joel Spicer, senior health specialist in the World Bank’s Africa region. Spicer emphasizes the importance of scaling up TB/HIV collaborative activities.
The World Bank’s Role
The Bank’s Africa region has renewed its commitment to tuberculosis control.
“The Global Strategy and Plan to Stop TB provides the strategic vision and backbone for the approaches pursued at the country level,” according to Miriam Schneidman, coordinator of the Africa Regional TB Team.
Working as part of the Stop TB Partnership, the region is intensifying and scaling up efforts in TB control through its portfolio of health and HIV/AIDS projects. The region is working in partnership with others and taking advantage of the tremendous progress made globally in developing policy guidelines and tools for TB control, says Schneidman.
Her colleague agrees.
“The Africa Region will mainstream TB interventions through existing operations while focusing on its core mandate to strengthen health systems,” says Ok Pannenborg, Africa Senior Health Advisor at the World Bank.
Providers at Jamot Hospital in Yaounde echo the views of others across Africa about the need to strengthen health systems. They emphasize the importance of having the right number of qualified staff, appropriate incentives to minimize turnover, and infection control measures to prevent contamination. Attrition is high among TB specialists at Jamot, as it is in other parts of Africa. This is not a field attracting new recruits.
“Working with TB patients places staff at great personal risk,” said one nurse at the hospital.
“Lack of new diagnostic tools, and inadequate laboratory capacity hinders detection and management of drug resistance, with catastrophic consequences when dealing with lethal forms of TB,” says Bert Voetberg, a lead health specialist in the World Bank’s Africa region.
Other aspects such as drug and logistic systems and health financing are equally important. In countries like Kenya, the Bank has played a pivotal role in ensuring that the needs of the TB program are well reflected in the health sector expenditure program. This process has led to an increased focus on TB, better harmonization between the TB and HIV budget processes, and improved costing of emerging needs such as drug resistance.
In Rwanda, Christine Uwiragiye said that she was in denial after her husband died of AIDS. When her 7-year old daughter, Florence, was admitted to Mibilizi Hospital for TB treatment, she was saddened to find out the child had AIDS. Christine’s story of denial and fear is not uncommon. In the case of Florence, she spent 40 days at the hospital for TB treatment and to initiate antiretroviral therapy. The young girl was then transferred to the Mashesha Health Center near her home which will make it easier to adhere to treatment. Florence is now able to resume a normal routine, joining her fellow first graders. In the absence of the government’s widely available treatment program for co-infected patients Florence’s young life might not have been spared.
"The theme for this year's World TB Day is 'I am stopping TB.' Clearly we can add President Robert Zoellick and the World Bank to this list," says Marcos Espinal, Executive Secretary of the Stop TB Partnership.