Study On The Implementation Actuality Of China Global Fund Multi-drug Resistant Tuberculosis Control Program In Shandong

BackgroundMultidrug-resistant TB (MDR-TB) is a threat to global TB control. As one of the 27 high MDR-T burden countries, low drug sensitive test coverage, under-developed diagnosis method, substandard treatment and management, low success rate of treatment, and heavy economic burden of MDR-TB patients existing in China.The pilot program on MDR-TB treatment with the support of China Global Fund TB Program started in China since 2006. China Global Fund TB Program put focus on MDR-TB control Since July 2010, which was called China Global Fund MDR-TB Program. Tuberculosis prevention and control institutions of county level were responsible for the sputum smear screening, and the municipal TB prevention and control institutions were responsible for sputum culture and drug sensitive test. MDR-TB patients receive 2 months of hospital treatment in MDR-TB designated hospitals and outpatient treatment of 22 months. China Global Fund MDR-TB Program provide hospitalization subsidy of $1700 per patient and free second-line anti-TB drugs of 24 months, as well as other subsidies. China Global Fund MDR-TB Program was divided into two phases. The first phase was from July 1,2010 to June 30,2013, and the extension phase was from July 1,2013 to June 30,2014. In the first phase, the screening object was five key crowds of MDR-TB, and in the extension phase, all smear-positive pulmonary TB patients need receive screening.ObjectiveThis study will analyze and evaluate MDR-TB case detection, patient treatment, patient management, treatment expenses, economic burden of MDR-TB patient and sustainability of MDR-TB prevention and control after the program in the five program areas of Shandong Province that covered in the program since the first phase, and to extract experiences and draw lessons, so as to give some ways and suggests for future MDR-TB prevention and treatment.MethodsThis study selects the all five program cities of Shandong Province that had been covered by Global Fund MDR-TB program since July 2010.This study focuses on municipal MDR-TB institutions and professionals, head of municipal MDR-TB designated hospitals, MDR-TB patients that had received six months treatment in Global Fund MDR-TB program. Research content includes the situation of MDR-TB case detection, patient treatment and management, treatment expense and economic burden of MDR-TB patients, and sustainability of MDR-TB prevention and treatment after Global Fund MDR-TB program.Tools for data collection includes structured data collection forms for regular data of municipal MDR-TB designated hospitals, structured self-administered questionnaire for MDR-TB professionals, semi-structured outline for hospital managers, and structured questionnaire for MDR-TB patients. Quantitative data was sorted and stored by Excel software. SPSS 18 software was used to complete the statistical analysis and statistical inferences of quantitative data. Qualitative data was analyzed through Framing Analysis Approach.Results1. Case detection of MDR-TBIn the first phase of program, screening rate of smear positive TB patients is 32%, screening rate of new smear positive TB patients is 25%; in the second period, screening rate of smear positive TB patients is 57%, screening rate of new smear positive TB patients is 56%. Work ability and the willingness to work of county levelTB designated institutions had a great influence on patient screening work.4% of new smear positive TB patients was diagnosed as MDR-TB, and 17% of retreatment smear positive TB patients was diagnosed as MDR-TB. Laboratory of municipal MDR-TB designated hospital cannot meet the equipment requirements that the program provided affected MDR-TB diagnosis.2. Treatment of MDR-TB72% of diagnosed MDR-TB patients were involved in the program for treatment, propaganda of MDR-TB and the program is helpful to promote MDR-TB patients received treatment in the program.Among all the 313 patients that had treatment outcomes, the cure rate is 35%, the rate of completing treatment is 4%, treatment failure rate is 15%, case loss rate is 18%, mortality rate is 18%, and the other cases account 9%. Poor compliance of MDR-TB patients is one of the important factors affecting patient treatment outcomes.3. MDR-TB patient management74.4% patients had received hospitalization in the program. Some patients were not willing to be hospitalized for freedom.97% patients take medicine at home. Only 20% patients has supervisor and supervisor had always been on scene when they taking medicine.81% patients that received visits said the healthcare providers who visited them were from municipal TB designated hospitals. Municipal MDR-TB designated hospital undertook most of treatment and management work.4. Hospitalization expense, out-of-pocket payment and disease economic burden of MDR-TB patientsThe median of hospitalization expense was 14063 Yuan. Expense of medicine is on the top and account 50% of all hospitalization expense. The difference of hospitalization expense among different cities is significant.The median of patients’out-of-pocket hospitalization medical expense was 8500 Yuan. The difference of patients’out-of-pocket hospitalization medical expense between different cities is significant.39% patients think their disease economic burden was very heavy,26% patients think their disease economic burden was comparatively heavy,12% patients think their disease economic burden is lighter, and only 3% patients think their disease economic burden is very light.5. Continuity of MDR-TB control after the programSustainability of MDR-TB control of LC, ZZ, and LY city was better than that of DZ and BZ city. The sustainability of MDR-TB control is influenced by work ability and willingness of TB medical institutions at the county level and below and local government support.ConclusionsPoor ability and attitude towards TB work of some TB designated hospitals influenced MDR-TB patient screening work; Global Fund MDR-TB program provided free drugs and different kinds of subsidies had promoted MDR-TB patients to receive treatment; Hospitalization and direct observed treatment of medical personnel strategy cannot meet the program requirements; Patients’ out-of-pocket medical expenses were still high and disease economic burden were still heavier despite the support of the program; Some cities face poor sustainability of MDR-TB prevention and treatment after the program for lack of government support.According the above conclusions, this study proposes the follow suggestions:1. Giving priority to infectious disease specialist hospital that had ability and strong participate willingness when determining TB designated hospital, at the same time take into account the nature of county level TB designated institutions, and set necessary supervision and incentives mechanism.2. Giving screening priority to recurrent smear-positive tuberculosis patients when resources were limited.3. Increasing subsidies for MDR-TB patients and strengthen propaganda and education of MDR-TB to promote patients receive treatment. Choosing hospitalization or outpatient model to treat and manage MDR-TB patients according to the local situation. The government should assign management of MDR-TB patients to the basic duties of primary medical organizations through government document.4. The government should provide free drugs for MDR-TB patients except anti-TB drugs, especially that used for adverse effect of anti-TB drugs.5. The government should play its role in MDR-TB control. The national and provincial TB-related departments should set up system to promote MDR-TB control to be regular work.