| BackgroundMulti-drug resistant tuberculosis has come to refer to cases in which the tuberculosis strain is resistant at least to isoniazid and rifampicin. It spreads through the respiratory tract, so once infected, the crowd becomes the primary multi-drug resistant tuberculosis patients. Multi-drug resistant tuberculosis needs to adopt expensive second-line anti-tuberculosis drugs for long cycle treatment.Because of the the high cost,low cure rate and high mortality, multi-drug resistant tuberculosis has great danger to society. In recent years, the incidence of tuberculosis especially the incidence of multidrug-resistant tuberculosis is on the rise, thus it attracted widespread attention. How to control multidrug-resistant tuberculosis becomes the hot spots in the study of whole society. The epidemic of multidrug-resistant tuberculosis in China is very serious. In2007the World Health Organization lists "27highly drug-resistant tuberculosis burden countries in the world", China ranked the second,and it bears about22%of the world’s total burden of multidrug-resistant tuberculosis. In2012, the World Health Organization global tuberculosis control report released in Geneva notes that China and India have the largest number of multidrug-resistant tuberculosis patients, and multidrug-resistant tuberculosis will continue threat to human health.The emergence of multidrug-resistant tuberculosis mainly due to the unreasonable medication,both from patients of the demand-side and the clinic management of the supply-side.The cooperative control of designated hospitals and tuberculosis control agencies had achieved remarkable results in many foreign countries.The Ministry of science and technology in China implemented the cooperation in2010, and will plan to make nationwide promotion. Therefore, an evaluation of its progress, discovering their strengths and weaknesses and making improvements is inevitable and urgent.However there are problems using the conventional contrast evaluation before and after:On one hand, before the intervention, the diagnosis of multidrug-resistant tuberculosis patients mainly didn’t rely on laboratory diagnosis but clinical experience. Therefore, the use of the patient’s condition before and after comparison is not precise enough. We did not carry out cooperation before the intervention, therefore, there were only with or without changes before and after for the comparison,with limited significance in guiding practice. On the other hand, the diagnosis of multidrug-resistant tuberculosis needs a period of time. Meanwhile, according to the research experience of the world, there will be a small number of patients. Therefore, our study can not use a large sample multivariate methods to control and can not use complex statistical methods for analysis.Combination of the above issues, we proposed research to evaluate the progress of the multi-stage. Finding its progress, we will achieve the purpose of continuous improvement and perfection. Therefore, our study is part of the overall process of the subject, reflecting the problems of this stage. The follow-up study and re-evaluation is necessary.The previous literature are mainly retrospective comparation,evaluating on before and after the intervention,using a small number of indicators, so the results of the evaluation is limited. Therefore, the design of our study is to establish the evaluation index system from the supply-side and demand-side, then make comparison between the early and mid-intervention. Evaluating the progress of cooperation,so we can provide policy recommendations on the nationwide promotion.AimsThe overall objective of the study is to establish a evaluation index system for cooperation through theoretical study and empirical practice, then to evaluate from the supply-side and demand-side between the early and mid-intervention. At last,we discuss the results to provide a scientific basis for nationwide promotion in the future. The specific purpose is to establish a evaluation index system for cooperation through theoretical study and empirical practice; then to perform empirical research so as to evaluate from the supply-side and demand-side between the early and mid-intervention. We will identify problems and analyze the reasons to put forward policy recommendations for the cooperation.MethodsThe data come from the Ministry of Science and Technology issue " tuberculosis incidence mode" twice intervene survey, including patients face-to-face surveys, institution surveys, medical record information surveys and key informant interview. We chose Henan, Heilongjiang, Zhejiang, Tianjin,Chongqing, as the research sites according to the baseline survey data for the provinces of multidrug-resistant tuberculosis, tuberculosis control level, geographical distribution and socio-economic conditions. A total of40insiders were interviewed separately in the early and mid-intervention.119patients were diagnosed between2010-03-01and2011-02-29,and the initial survey included38cases of patients with a total of59patients received treatment.235patients were diagnosed between2011-03-01and2012-02-29,and the second survey included63cases of patients with a total of107patients received treatment.We widely collected index of multidrug-resistant tuberculosis in China’s practice of cooperation,according to intervention plans,literature research methods and the expert group discussion in our study. We preliminary screened the evaluation index based on SMART principles. Delphi method expert consultation is used to identify evaluation index system. Fuzzy analytical hierarchy process is used for determining the weights of index. Then a scientific system of evaluation index system to evaluate the progress of the cooperation from the supply-side and demand-side was established,we compared the main index in the progress of the early and mid-intervention,according to the combined results of the survey and the principle of differences. we will conclude the proposed policy recommendations based on the results.Our study used a combination of quantitative and qualitative analysis method. Quantitative analysis included descriptive statistics analysis, and the key index including rate, mean, median, chi-square test, non-parametric tests. Qualitative analysis by induction method of Descriptive Analysis. We classified the interviews in accordance with the different themes, and then they were collated and analyzed based on the main points.Results(1) The situation of study area and patients with multidrug-resistant tuberculosis The largest population of the five research areas is94,290,000in Henan Province, The population of the least number is11,760,000in Tianjin. The per capita GDP was up to54000in Tianjin, and at least18000in Chongqing. The time of the baseline survey from1999to2005.the total multi-drug resistance of up to12.9%in Henan, and as low as4.60%in Chongqing o f the Five study sites. Daqing City in Heilongjiang Province, Puyang City in Henan Province and Quzhou City in Zhejiang Province are the gobal Fund Project Cities. Because of its high local fiscal revenue, the diagnosis and treatment of multidrug-resistant tuberculosis in Tianjin is mainly relying on local special support.Chongqing City is not a gobal Fund Project city, also because of its low local revenues, diagnosis and treatment of multidrug-resistant tuberculosis is mainly rely on Medicare to maintain.The patients involved in the investigation were with male to female ratio of2.37:1, and the age were from25-year-old to73-year-old with mean age45years. The patients age was divided by35,45,55,65, and the according proportion were31.7%,17.8%,17.8%,19.8%,11.9%. junior middle school education was37.6%as the largest proportion. Subsistence allowances or the proportion of poor households accounted for16.8%., unemployed or unemployment was41.6%as the largest proportion of Occupational characteristics, new rural cooperative was66.3%as the largest proportion of patients participated in Medicare, and patients did not participate in any Medicare ranked second, accounting for11.9%. The local accounted for84.2%, the proportion of the foreign accounted for15.8%.(2) Policy environment and organizational management Overall, the Policy environment and organizational management had progessed a lot in the second survey. The five cities had all established cooperation leading group with communication through regular meetings and telephone on the early evaluation. But there are still needs to be improved and perfected, especially the financing mechanisms which reveals a lot of problems.As the largest weight indicators,The financing source was not changed. The main improvement is the proportion of Chongqing Medicare reimbursement amount as well as the proportion of drugs into the health insurance directory. None of the other four cities Medicare policy progressed.(3) The cooperative system and service capabilitiesOnly the city of Tianjin and Puyang City, Henan Province developed incentive assessment mechanism on the early evaluation. To the mid-term evaluation, five cities all developed a dynamic substance incentives.There was no progress in the laboratory configuration. The municipal CDC were the most perfect, and they are able to carry out sputum smear, sputum culture and susceptibility testing. The county tuberculosis prevention agencies can perform sputum smear. The two cities:Puyang City, Henan Province, Daqing City, Heilongjiang Province couldn’t not conduct sputum culture. The municipal designated hospitals and municipal CDC progress is obvious for the infection control. The patient and the protection of medical personnel were not perfect in the early,but they are in place to medium-term. The designated hospital made ward transformation, enhancing infection control capabilities. The county tuberculosis prevention agencie’s control is relatively weak and there is no progress. The human resource were more complete in the medium-term than the early. The problem is that there are still only one laboratory assistant of some CDC in the interim.29.9%training coverage related to the training of the designated hospital doctors in the initial evaluation is the lowest. Therefore, the initial evaluation, the designated hospitals to participate in the training effect in the early is the poorest overall. Doctors training coverage increased both in the designated hospitals and CDC in the mid-intervention. The CDC doctors training coverage is higher than the designated hospitals in the early, and in the mid-intervention they are the same.We made comparative evaluation on service capabilities including sputum culture timeliness, timely susceptibility testing, the timeliness betrween drug result of feedback and treatment, timeliness and other aspects of the intervention in the early and mid-intervention. These aspects are both the most important manifestation of the ability of "cooperation" and the core index.(4) Patient’s service utilizationThe top five causes of the confirmed patients with multidrug-resistant tuberculosis that failed to receive treatment were death, mobile populations, lost of contact, economic difficulties, as well as distrust of the treatment.The detection and diagnosis of the patients improved significantly, including negative culture rate of sputum smear positive specimens, coated male sputum samples of sputum culture rate, the positive the strain identification rate of culture susceptibility testing positive patients, the screening rate as well as the average diagnosis time.Treatment of patients is part of the core indicators. However, due to the relatively short implementation time of the cooperation, only two patients’treatment was full six months,and none complete the whole course.56.1%of treated patients hospitalized in the mid-term evaluation, and there is a substantial increase compared to23.7%of the initial. The proportion of patients with sputum smear negative conversion of6months was63.0%, sputum culture negative conversion proportion was55.0%, the cure rate was41.0%at the end of the treatment in the mid-term evaluation.Patient management overall had great progressed,including patient tracking in place within the first six months, the proportion of patients to accept DOT within6months,the proportion of patients missing in the first6months, the implement of treatment and management. But not all the patients had been track in place.We are unable to calculate the economic burden of disease in patients initially. The total medical expenses mean was41,005.81yuan, with7387.84yuan of the patient-pocket costing,payingl8%in the interim.17of38patients had catastrophic health expenditure, the ratio was44.7%on the mid-term evaluation.(5) SatisfactionThe designated hospitals staff satisfaction with the cooperation increased than the early. The CDC staff satisfaction with the cooperation did not change in the early and mid-term intervention. The CDC staff satisfaction are higher than the designated hospital staff in both surveys.The satisfaction of patients for paying the proportion increased from55.3%in the initial to76.2%of the mid-term. The patients satisfaction with the services of the CDC and designated hospitals is more than80%both in the two surveys.Conclusions and policy implications(1) At present, the prevention and control of tuberculosis, especially multidrug-resistant tuberculosis is an important work requires participation of the whole society. So it is urgent to raise the awareness of prevention. We have to spread multidrug-resistant tuberculosis prevention and control knowledge as soon as possible by making it serve as a scientific knowledge into local health education plann.It needs to establish "government leading, multisectoral cooperation, the whole society participation" of regular operatinal mechanism about health education and promotion of multi-drug-resistant tuberculosis. It is good social support network that plays a crucial role in the patients’rehabilitation. When the patient is sick, he had increased dependency on medical services, and also need more understanding, caring and help. Building a good social support network helps patients fight diseases and increase confidence, so they can get well soon.(2) We have to remain the comprehensive cooperation organization building and timely coordination mechanism established in the early. And we can explore diversified incentive assessment mechanism in the future. A dynamic incentive assessment mechanism can be considered and adjusted based on the development status of the cooperation.(4) The cooperation funding sources must be addressed as a priority.①More local fund need to be mobilized to the cooperation, and also be conducted in the yearly routine local budget, so as to ensure the smooth progress of the work of the multi-drug resistant tuberculosis.②The health insurance policy of multi-drug resistant tuberculosis need to be improved. Because of its sustainability,the health care system will have srong support if inclined to multi-drug resistant tuberculosis.③The establishment of a medical assistance system need to be explored.(4) The municipal CDC is the srongest to participate in the cooperation of the various elements, and they significantly progressed in the interim. The limitation is that part of the research and cities had too small number of laboratory personnel. Therefore, we need to increase staffing of the laboratory in order to ensure the effectiveness and speed of the laboratory of cooperation. Meanwhile, the capacity of municipal CDC need to be continually improved in the prevention and control of multi-drug resistant tuberculosis to strengthen cooperation with the designated hospitals.(5)We should be fully aware that the designated hospitals in the the cooperation is in essential. Due to inadequate compensation, the designated hospitals are not enthusiastic in the cooperation. The compensation need to be increased and the long-term compensation mechanism need to be explored for the public health functions that designated hospitals bear.(6) Greater emphasis should be made on the basic preventing institutions and investment, increasing their level of configuration and their capacity to participate in the cooperation. Patients’knowledge should continue to strengthen to dispel their concerns and raise their awareness of protection, thus it can make a protective effect for both patients and doctors.(7) Patients need to be educated to correct the attitude of their treatment, to improve compliance, and to enhance their confidence of its cure. Various forms of compensation mechanisms need to be actively explored. A special compensation measures need to be established on the basis of the existing medical insurance. It is not enough for simple control of local registered permanent resident of multidrug-resistant tuberculosis patients for the increasing floating population. It is very promient in our study that the poor compliance and the incomplete treatment the floating population had. Therefore, more attention need to be given to floating population. Establishment of trans-regional tracking mechanism for patients in floating population is necessary and the track work should be carried out as soon as possible. |
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