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