Academic journal article Bulletin of the World Health Organization

Increasing Tuberculosis Case Detection: Lessons from the Republic of Moldova/Renforcement De la Detection Des Cas De Tuberculose: Enseignements Provenant De la Republique De Moldova/Aumentar la Deteccion De Casos De Tuberculosis: Ensenanzas De la Republica De Moldova

Academic journal article Bulletin of the World Health Organization

Increasing Tuberculosis Case Detection: Lessons from the Republic of Moldova/Renforcement De la Detection Des Cas De Tuberculose: Enseignements Provenant De la Republique De Moldova/Aumentar la Deteccion De Casos De Tuberculosis: Ensenanzas De la Republica De Moldova

Article excerpt

Introduction

The Republic of Moldova adopted the DOTS strategy in 2001 and committed to reaching the global tuberculosis (TB) targets of 70% case detection and 85% treatment success. (1) At the same time, the Republic of Moldova initiated health system reforms, reorienting towards primary health care (PHC) and introducing national health insurance. International donors supported TB control and reforms designed to increase the demand for, and supply of, services. This paper reviews TB case notification in the context of interventions during 2001-2005 to extract early lessons of the Republic of Moldova's experience. What contributed to detection of new smear-positive cases increasing from 37% in 2001 to 65% in 2005? (2) What practical approaches can the Republic of Moldova share with other low-income countries in increasing detection?

Methods

The method used is to juxtapose TB case notifications, sputum smear microscopy (SSM) confirmation, TB diagnostic investigations and PHC patient visits against the timeline of interventions during 2001-2005. These data were selected because they should capture the effects of improved diagnosis, laboratories, surveillance and public awareness. The selected period coincides with the introduction and expansion of DOTS to the entire country; integration of TB and PHC services; and amended payment mechanisms for services. It was a period of intensive effort by the Republic of Moldova to institute internationally recommended policies. Although case detection increases cannot be attributed rigorously to specific interventions, they indicate the relationship between global targets and reforms advocated by international organizations. With additional data and analysis, precise attribution and confirmation of these indications may be possible.

Data presented in this paper were obtained from the National Tuberculosis Program (NTP) and the Ministry of Health (MoH) of the Republic of Moldova. The data cover all of the Republic of Moldova, including Transnistria (a frozen conflict region) and the penitentiary system. Because of data coding and verification revisions related to health insurance and the TB surveillance system, comparable data in some cases are available only for 2004-2005.

Results

Fig. 1 and Fig. 2 show the trends. Fig. 1 depicts the number of all (new and relapse) TB cases notified; the number of new TB cases notified; the per cent of pulmonary TB cases confirmed by SSM; and the timing of principal TB interventions during 2001-2005. Fig. 2 depicts the number of suspected TB patients for whom diagnostic investigations were conducted during 2003-2005 and the number of PHC patient visits for all causes during 2004-2005. Prior to 2004, PHC patient visit data are not comparable because reporting was revised when national health insurance was enacted in January 2004. For TB diagnostic investigations, the data began to be compiled when the network of microscopy laboratories was established in 2003 and increased when the network was completed in 2004.

[FIGURE 1 OMITTED]

TB control and health-care reforms

The National Programme for Tuberculosis Control in the Republic of Moldova for 2001-2005 reoriented the Republic of Moldova's TB system to the WHO-recommended DOTS strategy. In November 2001, the NTP initiated a civilian DOTS pilot programme, preceded by initiation of DOTS in penitentiaries in November 2000. As Fig. 1 shows, DOTS expanded rapidly and 100% coverage was achieved in January 2004. The full coverage of DOTS coincided with the introduction of obligatory national health insurance, which finances a package of health-care services, including tuberculosis diagnosis and treatment. For TB diagnosis, the insurance system contracts with PHC practitioners on a per capita basis and covers laboratory tests and personnel. For TB treatment, the insurance system contracts with hospitals per treated case and covers patient stays, laboratory tests and drugs for treatment of chronic cases and latent infection. …

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