One Project in Ethiopia Shows Us That Investing in Health Systems Pays Dividends
By Jordan Coriza
Over the past five years, the Ethiopian government and MSH have been working shoulder to shoulder to improve and expand the country’s tuberculosis services with the goal of alleviating the burden of the disease.
If you wonder whether foreign assistance is money well spent, just look at the remarkable progress we’ve made in Ethiopia, where only a few years ago the stock out rate for TB drugs was as high as 20 percent. That number today is about two percent.
Our tuberculosis work in Ethiopia supported 55 million people between 2010 and 2016. During that period, we improved case detection, diagnosis, and treatment mechanisms; strengthened the laboratory capacity of more than 2,000 facilities to diagnose TB; improved the supply management of TB drugs; and trained tens of thousands of health workers at all levels of the health system.
The upside is not just the thousands of lives saved or improved, but the strengthening of a health system that is now better equipped not only to respond to TB, but also to other diseases, therefore helping the people of Ethiopia live healthier lives, contribute to their economy, and make their country a more stable and peaceful place to live.
BEHIND THE SCENES
The project is called HEAL TB, which stands for Help Ethiopia Address Low TB Performance. Funded by USAID and implemented by Management Sciences for Health (MSH) and a number of partner institutions, the objective of the program is to support Ethiopia with a comprehensive package of TB interventions to provide better detection, diagnosis, and treatment, as well as strengthen referral linkages between health facilities and communities in need.
But the beauty of the program lies in its health systems approach — tackling a disease by addressing the various points in a health system that are key to creating a sustainable way of preventing and treating that disease.
In the case of HEAL TB, this included work in the following areas: case detection and reporting; TB in children; capacity strengthening of laboratories; patients with coinfections of TB and HIV; supply management of TB drugs; multi-drug resistant-tuberculosis (MDR-TB) service expansion; capacity building of TB program staff; and operational research.
AN EXEMPLARY APPROACH TO TREATING PATIENTS WITH MDR-TB
A major challenge at the outset of the project was that Ethiopia only had two hospitals that could admit an MDR-TB patient for treatment. With a mix of ambulatory and inpatient treatment models designed by the country’s Ministry of Health, 23 “treatment initiating centers” were established in the project’s two focal regions, and more than 300 follow-up centers were established for patients to get their “directly observed treatment” or DOT, a control strategy recommended by the World Health Organization. HEAL TB built three MDR-TB centers and equipped and trained staff in all 23 hospitals.
By 2016, more than 1,000 MDR-TB patients had started treatment, an increase from 50 patients when the project started.
How did we do this? Training health workers, continuing medical education for clinicians, and proper patient follow-up were the major processes that contributed to improving the treatment outcomes of MDR-TB patients.
For example, patients on follow-up took their DOT at a nearby health center, then once a month returned to an MDR-TB treatment initiating hospital for their clinical checkup, gave a sputum sample and other samples for treatment monitoring, and collected their supplementary food items. Their travel costs were also reimbursed on the same day. This arrangement helped the MDR-TB teams, including administrative staff, dedicate the day to MDR-TB patients and save the remaining days for other hospital tasks. The laboratory professionals conducted the lab tests locally, collected sputum for culture, and transported samples to culture facilities in one batch.
If a patient did not appear on the MDR-TB clinic day, a message was sent to the health center to track the patient and send a health worker for follow-up. If the sputum and culture did not convert at the expected time, treatment adherence was assessed. Contact screening of MDR-TB index cases was also done by the health center or the hospital.
A STRONG FOUNDATION FOR THE FUTURE
Another critical aspect of the program was to build the capacity of TB program managers and the skills of technical staff. Over the course of its five years, HEAL TB trained more than 27,000 health workers on anything from TB, leprosy, and TB/HIV services to TB program management and coordination, and fluorescence microscopy for lab staff. The sessions were organized in collaboration with Ethiopia’s Ministry of Health and led by district-level workers. These local teams were also involved in the planning, implementation, and monitoring and evaluation of the project, with the ultimate goal of creating sustainability.
A look at the treatment success rate of 94 percent and the overall decline in cases notified tells us the project is yielding good results.
If this success is sustained, the incidence of TB will continue to decline, the MDR-TB burden will decrease, and the country will be far along the path to achieve the End TB targets of the World Health Organization.
For further information, download the final project report: The Rapid Expansion of Comprehensive, High-Quality Tuberculosis Services in Ethiopia.