Case Study of National Tuberculosis Programme Implementation in Nepal

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Case Study of

National

Tuberculosis

Programme

Implementation

in Nepal

October/November 2002

Neil Hamlet,

Sushil Chandra Baral

World Bank

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List of Abbreviations and Acronyms

ARI Annual Risk of Infection

BNMT Britain Nepal Medical Trust

CBO Community based organisation

CCC Central Chest Clinic

CTLHP Community TB and Lung Health Project DfID Department for International Development, UK

DHO District Health Officer

DoHS Department of Health Services

DOTS Directly Observed Treatment Short-course DTLA District TB/Leprosy Assistant

EDPs External Development Partners

EHCS Essential Health Care Services FCHV Female community health volunteers GENETUP German Nepal Tuberculosis Project HEFU Health Economics & Financing Unit

HeSo Centre for Health and Social Development, Norway

HMG His Majesty’s Government of Nepal

HSR Health Sector Reform

INF International Nepal Fellowship

INGO International Non-governmental organisation I-PRSP Interim Poverty Reduction Strategy Paper

IUATLD International Union Against TB and Lung Disease

JAT Japanese Advisory Team

JICA Japanese International Co-operation Agency LHL Norwegian Heart and Lung Association LMD Logistics & Management Division MCHW Maternal and child health worker

MDGs Millennium Development Goals

MoH Ministry of Health

MTEP Medium Term Expenditure Programme (or Framework)

MTSP Medium Term Strategic Plan

NATA Nepal Anti-TB Association

NGO Non-governmental organisation

NHS National Health Service, UK

NIH Nuffield Institute of Health

NLR Netherlands Leprosy Relief Association

NORAD Norwegian Government Aid

NTC National Tuberculosis Centre

NTP National Tuberculosis Programme

PHC Primary Health Care

QC Quality control (microscopy)

QCA Quality control assessors

RCT Randomised controlled trial

RIT Research Institute of Tuberculosis (Tokyo, Japan)

RMS Regional Medical Stores

RTC Regional TB Centre (Pokhara, Western Region)

RTLA Regional TB/Leprosy Assistant

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SCC Short Course Chemotherapy

SEARO WHO South East Asia Regional Office

SLTHP Second Long Term Health Plan

STC SAARC TB Centre

SWAp Sector Wide Approach

TAG Technical Advisory Group

TB Tuberculosis

TBCP TB Control Project

TLP Tuberculosis Leprosy Project (INF)

ToT Training of trainers

TQM total quality management

UMN United Mission to Nepal

VDC Village development committee

VHW Village health worker

WHO World Health Organisation

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Executive Summary

Study context

The National TB Programme (NTP) of Nepal is generally regarded as highly successful both nationally and internationally. The programme has never previously been studied to identify the key success factors both from the perspective of technical TB control implementation and generic health service functions. The impact of Health Sector Reform (HSR) on programmes such as TB control is a live topic of debate internationally and also in Nepal where an HSR process is currently in the late stages of planning. From these two perspectives Nepal provided an ideal case study opportunity to examine the NTP in the climate of imminent HSR. This work was commissioned by the World Bank.

Review process

Two short-term consultants (one national, one international) with considerable working experience of TB control in Nepal were contracted to undertake the review over a two-week period in late autumn 2002. Information was gathered by interviews, site visits, correspondence and the examination of relevant documentation (in English). The world literature on HSR and TB control was explored to provide a framework for the work. The document was peer-reviewed prior to publication.

Tuberculosis control in Nepal

TB causes an estimated 8,000-11,000 deaths per year in Nepal. In the year 2000/01 over 31,000 TB patients were registered and treated under the NTP, of which 13,000 were new smear positive. The NTP was revised in 1995 and DOTS implemented in 1996. By mid-2001 the DOTS strategy had been rolled out to 227 treatment centres with 684 sub centres, covering 84% of the total population across all 75 districts in the country. Treatment success rates of 85% or greater have been reported over the past 5 years.

The NTP and lessons for the Nepal health sector

Examination of the Nepal TB Programme provides insights of value across the health sector in terms of generic issues such as programme management, organisational culture and implementation practices.

The areas highlighted as being key success factors were: x Leadership and a strong team approach

x Staff motivation x Communication

x Peer review practices including the sharing of best practice x A clear central policy but encouraging local innovation x High quality technical assistance at national and regional level x Focused and consistent external donor partners

x Partnership working practices

x Appropriate and phased decentralisation

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The NTP and health sector reform

The overarching objective of HSR is threefold: to maximise efficiency, equity and quality. The process involves the defining of priorities, the refining of policies, and the reforming of institutions through which these policies are implemented.

His Majesty’s Government of Nepal (HMG) have set three programme outputs which will be at the core of the Nepal HSR programme over the next 5 years. These are an Essential Health Care Service (EHCS) package, decentralisation, and a public-private mix of service provision.

The potential of the NTP to champion, or conversely, to hinder HSR change is addressed together with an analysis of the impact that HSR may have on the delivery of TB control. The eight Nepal HSR outputs and seven key areas identified by the TB/HSR literature are used as a template against which to evaluate the Nepal situation.

The strengths of the NTP in relation to maintaining quality TB control services during the HSR process are; the commitment to widespread advocacy, the close monitoring of anti-TB drug procurement and delivery, the retention of technical supportive structures for microscopy services and trimesterly cohort reporting mechanisms, the emphasis on service delivery through the PHC system and the awareness of ‘NTP’ donor partners of the HSR process.

The weaker aspects are a lack of pro-active participation of the NTP in the reform planning process, no evidence of advance planning to prepare for the implications of HSR on TB control programming and an absence of plans to pilot test the new institutional arrangements arising from the HSR process.

Partnerships and resourcing of the NTP

One of the successful features of the Nepal NTP has been the ability to negotiate effective working partnerships and attract the required resources both financial and technical to implement an expanding programme of work. The preparation of detailed and budgeted 5-year development plans has been the foundation of this success. Sustained political and media advocacy has secured widespread awareness and support of the programme both nationally and internationally. An external review of the programme in 1994 became the catalyst for the revised NTP and led to a strong working partnership between the programme, external donors and a number of established in-country international development NGOs. Much of the non-government support provided to the NTP is in the form of technical assistance, training, supervision and service delivery mechanisms which are not currently quantified in NTP budgets. Currently therefore only an estimate can be made of the true resource envelope required for the NTP. Additionally not all financial flows are documented in the Ministry of Finance annual budget known as the ‘Red Book’. The NTP has demonstrated excellent capability to utilise government development budget ‘released funds’. This is a measure of the planning and implementation capacity of the programme. The sustainability of the current donor and implementing partner INGOs for the next 5-year phase requires exploration as two of the regional counterpart INGOs are currently undergoing restructuring. Additional challenges lie in the expected impact of HIV and the increasing attention being given to the syndromic approach to adult lung health.

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Local application of the DOTS strategy – lessons for the

region

A major component in the success of the adoption of the DOTS strategy in Nepal lies in the structured and phased manner in which the key operations for implementation were addressed. Using the 2002 WHO publication DOTS Framework for Effective TB Control as a template the lessons for other TB programmes in the region are defined. These are summarised as:

x Provision of adequate central unit office facilities for the NTP.

x A robust national review in 1994 leading quickly into the preparation of a development plan.

x Choice of external consultant is important as is the continuity of leadership of the NTP director in the period of any major revision of the NTP.

x A well developed national TB manual prepared in advance of any implementation. x The introduction of the cohort based TB reporting documentation requires to be

handled as a project in itself.

x The availability of adequate financial resources to back a comprehensive, locally adapted, rolling training programme.

x The widespread use of the WHO training modules to increase technical capacity for senior staff and trainers.

x The expansion of training into generic health care support roles and wider civic society.

x Recognition of the crucial importance of available microscopy services for a functioning DOTS programme.

x The DOTS expansion programme consisted of a comprehensive package of new site selection and preparation based on the 10-point checklist.

x Public (PHC and hospital), private and NGO facilities were used for service delivery.

x The management of drug supply has been closely monitored and controlled by the central unit providing the fast expanding programme with the security of uninterrupted supplies.

x The supervision programme is an example of excellent partnership working between government staff, ring fenced donor support, and local capacity building by ’on the ground’ INGOs.

x The emphasis on proactive communication and networking at all levels was instrumental in the success of the programme.

x The partnership working between the NTP and the press provided wide local and national press and radio coverage, increasing awareness of, and confidence in, public attitudes towards TB and its treatment.

x The Nepal programme had a culture of working with different agencies in the control of TB which promoted the inclusion of new private and voluntary partners.

x The NTP has effectively resourced external assistance in the process of budget formulation and achieved good release of funds.

x The attention given to practical operational research has driven up technical capacity of both individuals and the programme as a whole.

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Introduction

Study terms of reference

Purpose: To produce a case study analysis of the NTP in Nepal with the following 3

specific objectives:

1. To provide lessons for public health, primary care and health sector development in Nepal based on the successes and remaining challenges of the NTP and its integrated service delivery system.

2. To assess the level of funds available for the NTP from public and external sources, historical trend, assurance of financing for the next 3-5 years.

3. To summarise lessons for other countries on local adaptation and application of the recommended TB control strategy known as DOTS.

The complete terms of reference are in annex 1.

Linkage to other areas of research

The Tuberculosis Strategy and Operations Unit in the Stop TB department of WHO is currently proposing to initiate a systematic review in 3 countries in collaboration with the Centre for Health and Social Development (HeSo), Norway. The countries selected are Nepal, Tanzania and Uganda. The purpose of this larger work is to explore the evidence as to how and to what extent vertical programmes contribute to or interfere with health system development.

This World Bank Report will complement this evidence base by providing a case study approach to overlapping issues.

Methodology

Information was collected over a 2-week period in Nepal. The dates coincided with those of an international review team who undertook an in-depth technical assessment of the TB programme. This allowed the authors to gain valuable access to related documentation, interviews with key international and national review team members and participate in the briefing and field report meetings. Documentation was obtained from a wide variety of sources including World Bank, Ministry of Health, External Donor Partners and local implementing INGOs. Semi-structured interviews were conducted across a wide range of stakeholders. Drafts of the report were peer reviewed by selected international experts and local key stakeholders (see annex 7).

Constraints

The consultants were scheduled to join one of the review field teams however this had to be cancelled at short notice due to lack of security clearance. Interview appointments were difficult to schedule at short notice particularly with senior government health officials. This problem was compounded by a national strike day.

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Background information

Country profile

Nepal is a landlocked country lying along the Himalayan chain. Rectangular in shape, the country is 885 kilometers in length (east to west) and 193 kilometers in width (north to south). It shares its northern border with the Tibetan autonomous region of the People’s Republic of China and its eastern, southern, and western borders with India. The total land area is 147,181 square kilometers and the population, according to the 2001 Census preliminary report, is approximately 23.2 million. The population has doubled in 30 years. The population growth rate increased from 2.1 in 1971 to 2.6 in 1981, then declined to 2.1 in 1991.1 The population density has doubled over the last three decades from 79 persons per square kilometer in 1971 to 158 persons per square kilometers in 2001. Nepal is predominantly rural; nevertheless, the urban proportion has increased steadily over the last 30 years, from 4 percent in 1971 to 14 percent in 20012.

Topographically, Nepal is divided into three distinct ecological zones. These are the mountains, hills and terai (or plains). Of the total population, 49% live in the terai, 44% in the hills, and 7 % in the mountains. For administrative purposes, Nepal is divided into 5 development regions, 14 zones and 75 districts. Districts are further divided into village development committees (VDCs) and urban municipalities. At present, there are 3,914 VDCs and 58 municipalities in Nepal. Nepal is a multi-ethnic and multi-lingual society. The 1991 Census identified 60 caste or ethnic groups and sub groups of the population and 60 different languages or dialects prevalent in the country.

Nepal’s economic development has been severely constrained by challenging geographic, topological and socio-cultural environments. Latterly the unstable political situation has further fuelled the difficulties facing the nation. Nepal is defined as a poor country where the estimated per capita gross domestic product (GDP) for the year 1999/2000 is US $244. About 80% of Nepalis rely on agriculture for their livelihood. Forty-eight percent of GDP comes from the service sector, 42% from the agricultural sector and the remaining 10% from manufacturing.3

Table 1: Basic Demographic Indicators

Indicator 1971 Census 1981 Census 1991 Census 2001 Census

Population(millions) 11.6 15.0 18.5 23.1

Increased growth rate (%) 2.1 2.6 2.1 2.2

Density(pop/km2) 79 102 126 158

Percent urban (%) 4.0 6.4 9.2 14.2

Life expectancy (age) Male Female 42.0 40.0 50.9 48.1 55.0 53.5 Unknown Unknown Source- Central Bureau of Statistics 1995 and 2001

1

Central Bureau of Statistics, 1995 2

Central Bureau of Statistics, 2001 3

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National health situation

The overall goal of health care in Nepal is to improve the health situation of the people providing them with preventive, supportive, curative and rehabilitative health care services and provide support for poverty alleviation.

The population is diverse in Nepal. The mountainous terrain and geographic conditions isolate the primary rural population, many living below the poverty level. Such conditions provide a particular challenge to providing health care to all. As in many countries it is difficult to persuade health staff to work in the rural and remote areas and this is reflected in staffing of His Majesty’s Government (HMG) health facilities. In addition NGOs and private health care providers are concentrated in the better-off regions of the country.

Estimates of Nepal’s relative burden of disease were undertaken in 1997. The ‘burden of disease’ study indicated that infectious diseases, nutritional disorders and problems related to reproduction dominate the overall pattern of morbidity in Nepal. The main causes of death and disability are infectious and parasitic disease, perinatal and reproductive health problems. The highest risk groups are children under five, (particularly females who accounts for 52.5% of all female deaths) and women of reproductive age.

The burden of disease study estimates emphasised that the needs of children and mothers are not adequately met by the existing health delivery system.

In the case of adult males (15-44 years), tuberculosis (TB), accidental falls, acute respiratory infections (ARI) and motor vehicle accidents were the leading causes contributing to the burden of disease for that age group. For females in the same age group the burden of disease was attributed to maternal disorders, tuberculosis, burns and major affective disorders. There is evidence of an increase in newly emerging and re-emerging diseases namely; malaria, kala-azar, Japanese B encephalitis, tuberculosis and HIV-AIDS.

The issue of equality of access to health care compounds the impact of the burden of disease. In Nepal the major equity issues relate to gender, age, caste, ethnic group, income and area of residence (urban, rural, mountain, hill & terai). Transport costs are a significant deterrent to the poor in accessing health care in the remote areas.

Despite such shortcomings Nepal has made significant improvement in some health care indicators during past years as a result of planned development. The child mortality rate has decreased from 107 per 1,000 live births in 1987 to 64 per 1,000 live births in 2000 and the maternal mortality has also decreased from 580 per 100,000 live births to 539 during the same period.4 Similarly the user percentage of family planning devices has increased from 3% in 1976 to 39% in 2001. There has also been considerable progress in the provision of childhood vaccinations, tuberculosis and leprosy control, malaria, kala-azar, and diarrhoea control programmes.

However, the health care indicators show that overall the health care service has not progressed satisfactorily in Nepal in comparison to other countries. A summary of the progress made in the health sector is provided by the report of the Ninth Development Plan which spanned the period 1997 – 2002.

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Table 2: Target and Progress of the Health Sector during Ninth Plan (1997-2002)

Target and progress of the health sector during ninth plan

Health Indicators

Target Progress achieved by 2002

Coverage by basic health services (%) 70 70

Maternity services provided by trained workers (%) 50 13

Family planning device users (%) 36.6 39

Total period fertility rate (live births per woman) 4.20 4.1 Crude birth rate (live births per 1000 total population per

annum) 33.1 34

Infant mortality rate (deaths from 1st day of life to end of 1st

year of life per 1000 live births per annum) 61.5 64

Child mortality rate (per 1,000 live births per annum) 102.3 91 Maternal mortality (per 100,000 live births per annum) 400 539** Crude death rate (deaths per 1000 total population per annum) 9.6 10

Life expectancy (years) 59 59

Total hospital beds (government and private) -

-x Government - 5023

x Non-government -

-Primary health centres - 160

Health posts - 710

Sub-health posts - 3167

Skilled human power - 24800

Number of women health workers -

-Number of hospital including district, zonal, regional,

sub-regional, Ayurvedic and central hospitals - 85*

* Hospitals under the Ministry of Health only; ** According to Nepal Demographic and Health Survey of 1996 Source: HMG, MoH Tenth Health Plan 2002

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The status of TB control in Nepal

Tuberculosis is one of the foremost public health problems in Nepal, causing a significant burden of morbidity and mortality. About 45% of the total population is infected with TB, out of which 60% are adults (aged 15-64). Every year, 44,000 people develop active TB, of whom 20,000 have infectious tuberculosis. TB causes an estimated 8,000-11,000 deaths per year5. In the year 2000/01 over 31,000 TB patients were registered and treated under the NTP, among them about 13,000 are new smear positive1.

Case notification

Since the implementation of DOTS, case notifications of new smear positives have increased. This is a reflection of the increased coverage of the revised NTP

implementing the DOTS strategy.

Case notification trends in NTP

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 year Cases notified

No.Cases New P+ No.Cases New P-ve

No. Cases EP No. Cases Retreat

DOTS implement

ation

Figure 1. Case notification trends in NTP (new smear positive cases only) Source: Annual Report of NTP 2000/01

Treatment outcome

Treatment outcome under NTP seems sustainable and increasing after implementation of DOTS strategy. In 1996 DOTS was limited only in four centres. By July 2001 DOTS expanded to 227 treatment centres with 684 sub centres, covering 84% of total population in 75 districts. According to the NTP annual report global target of treatment success 85% has been achieved by NTP under DOTS strategy.

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Annual Report of National Tuberculosis Control Programme, National Tuberculosis Centre, Nepal 2000/2001

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Treatment Outcomes in NTP

0% 20% 40% 60% 80% 100% T.Out 4 32 22 54 72 Defaulted 10 109 201 250 570 Died 7 62 49 285 512 Failure 4 26 148 86 128 Treatment success 264 1542 3050 4849 8396 1996/97 1997/98 1998/99 1999/00 2000/01

Figure 2: Treatment Outcomes in NTP by annual cohort analysis

Source: NTP annual report 2002

TB and HIV

Four surveillance surveys of HIV infection among patients with TB have been undertaken in Nepal. The results of the surveys show an increasing trend of HIV infection among patients with TB from 0% in 1993/94 to 2.44% in 2001/2002. The survey indicates that 84% of HIV-TB co-infections occur in men between the age of 25 and 55 years.

MDR TB

Since 1996 surveillance of anti-tuberculosis drug resistance has been conducted with the co-operation of the World Health Organization, NTC and GENETUP. Latest anti-tuberculosis drug resistance survey shows ‘any resistance’ at 16.5% (11.0% in new cases and 40.9% in previously treated cases). Multi-drug resistance was 4.9% (1.3% in new cases, 20.5% in previously treated cases). The resistance pattern in re-treatment patients was Isoniazid, (33.3%), Streptomycin (31.1%), Rifampicin (20.5%) and Ethambutol (9.9%).

Compared to the survey of 1998-1999 multi- drug resistance in new cases has declined from 3.6% to 1.3% (p<0.01), any form of resistance from 13.2% to 11.0% and resistance to all four drugs from 1.8% to 0.8%. In previously treated cases drug resistance has increased. Multi drug resistance has increased from 12.5% to 20.5%, any drug resistance has increased from 28.6% to 40.9% (p<0.05). However resistance to all 4 drugs has decreased from 9.8 % to 9.4%. The reduction in resistance in new cases is likely to be the result of the successful DOTS programme during the last three years.

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Anti-TB drug resistance surveys

Pattern 1996-1997 1998-1999 2001-2002

Primary Acquired Primary Acquired Primary Acquired

Total tested 787 (100%) 0 673 (100%) 112 (100%) 755 (100%) 171 (100%) Any resistance 77 (9.8%) 0 89 (13.2%) 32 (28.6%) 83 (11.0%) 70 (40.9%) Mono-resistance 45 (5.7%) 0 51 (7.6%) 13 (11.6%) 53 (7.0%) 22 (13.0%) Multi-drug resistance 9 (1.1%) 0 24 (3.7%) 14 (12.5%) 10 (1.32%) 35 (20.5%) Resistance to all 4 drugs 0 0 12 (1.8) 11 (9.8) 6 (0.8%) 16 (9.4%) Table 3: Anti-TB drug resistance surveys in Nepal

Source: NTC

Development of the health policy agenda in Nepal

The policy framework for Nepal’s health sector has undergone significant developments in the last 10 years. Following restoration of multiparty democracy in 1990, a new National Health Policy was introduced in 1991. This paved the way for the newly created Department of Health Services under which a strong focus was the strengthening of primary health services delivered through a network of Primary Health Care centres (205 – one per electoral constituency), Health Posts (712) and Sub-health Posts for every Village Development Committee (3138). National planning is normally undertaken by means of ‘Five Year Development Plans’ which are published by the National Planning Commission. The 8th (1992-1997) and 9th (1997-2002) five year health plans focused on this extension of basic services to rural communities together with a policy of strengthening health service management, technical supervision, monitoring and evaluation. The 9th plan also identified the district as the focal point for decentralised planning and management of health care services.

The production of the Second Long Term Health Plan (SLTHP 1997-2017) provided the broad framework from which the 20 components of the Essential

Health Care Services (EHCS) package were identified as priority programmes. The

control of infectious diseases including tuberculosis was one of these named priority elements.

In order to build on the work of the SLTHP, reassess the capacity of the health system and develop a more coherent approach to planning and development in the health sector a document entitled a Strategic Analysis to Operationalise the Second Long

Term Health Plan was produced by a consortium of Government Ministries, the

National Planning Commission, the World Bank, External Development Partners (EDPs) and International Non-Governmental Organisations (INGOs) in early 2000. Four actions were proposed from this report:

x Strengthening health service delivery x Decentralisation

x Actions to improve the public-private-NGO mix x Strengthening sectoral management

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An additional key driver in the analysis of health care resources and policy development was the preparation and publication of the World Bank Report ‘Nepal,

Operational Issues and Prioritisation of Resources in the Health Sector’, June

2000. This report generated 5 recommendations: x Increase political commitment

x Focus on Group 1 diseases (which included tuberculosis)

x Develop institutional capacity – by creating a strategic framework and using existing resources efficiently and effectively

x Develop better health care systems – by developing public-private partnerships x Establish priorities – by identifying sequenced priority interventions

Together these two comprehensive reviews highlighted the strategic areas for the preparation of the Medium Term Strategic Plan (MTSP) which was published by His Majesty’s Government in February 2001. This document in the form of detailed logframes laid out the four areas for strategic interventions to be incorporated into the health sector component of the 10th Five Year Development Plan 2002-2007). The MTSP was also a tool to provide a basis for the development of a sector-wide approach and to guide collaboration and investment by development partners and agencies.

Table 4: Goal and Purposes of Medium Term Strategic Plan

Goal:

Health status of the Nepalese population improved through a health care system that provides equitable access to quality health care

Purposes:

1. An effective health system developed for the provision of affordable and accessible EHCS

2. Public-private-NGO partnership in health care provision promoted

3. Effective decentralisation in health system provision ensured with participatory approaches at all levels

4. Improved quality of health care provided by public-private-NGO partnership through total quality management (TQM) of human, financial and physical resources

Following on from this work was the preparation of the Medium Term Expenditure

Programme (MTEP)6 to Operationalise 1st Three Years of 10th Five Year Plan’s

Health Programmes, January 2002. This document also embraced the requirements

of the Interim Poverty Reduction Strategy Paper (I-PRSP) for Nepal. Key programmes and activities were prioritised into 3 groups. Tuberculosis control was identified as one of the Priority 1 Programmes based on the parameters of: burden of disease, implementation capacity, equity consideration, programmes directed to the poor, marginalized, vulnerable and disadvantaged groups, programmes contributing to poverty alleviation and availability of resources. The document identified the inability to clearly determine financial requirements for the health sector and makes a number of recommendations including:

x The creation of ‘national health accounts’ covering public, private, NGO and EDP health sector expenditures at all levels of the health system

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x The establishment of a health economics body to provide technical support to the Ministry of Health (MoH) on health financing issues.

x Develop a common financial reporting framework for all EDPs. Interestingly the document notes that, ‘the process could build on steps already taken to develop sub-sector programmes such as TB, leprosy and reproductive health.’

The implications of the MTEP for donor assistance and donor behaviour is discussed along with the declaration of HMG to identify the 10th Five Year Development Plan

as the Nepal Poverty Reduction Strategy Paper. Finally the document encourages a move towards a Sector Wide Approach (SWAp) in order to optimise available resources from EDPs.

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Millennium Development Goals

HMG/N was a signatory to the Millennium Declaration in September 2001. The first progress report on the status of attainment of the Millennium Development Goals (MDGs)8 in Nepal was published in February 2002. These 8 goals and 18 targets aim to create an environment conductive to development and the elimination of poverty. The health sector is particularly involved in 5 of these targets. In particular, target 8 sets out 2015 as the year by which the incidence of malaria and tuberculosis should be halted & reversed. The identification of TB in the National MDGs is highly significant for the prioritisation of the national TB control effort.

Local Self Governance Act (1999)

This act established a framework for decentralisation to the district level. It would involve increased responsibilities for health care delivery being devolved to District Local Development Committees. The full implementation of this Act is scheduled to take place during the 10th Five Year Development Plan period 2002-2007.

The Health Sector Reform Process in Nepal

In May 1997 a meeting was held in Kathmandu involving HMG and EDPs to consider a more coherent approach to planning and development within the health sector. Despite general agreement at that time little follow up action occurred. In 1999 following an assessment of stakeholders to support a government led joint strategic analysis of the health sector the HMG expressed a clear wish for EDPs to move towards a sector wide approach in planning and delivering health care.

The initial outcome of this work was the preparation and publication of the Strategic

Analysis to Operationalise the Second Long Term Health Plan in May 2000.

Together with the policy framework contained in the 1991 National Health Policy

and the SLTHP this work progressed into the formulation of the MTSP and MTEP as route maps for the health component of the 10th Five Year Development Plan (2002-2007). The reform process is led by a Health Sector Reform Committee and chaired by the Health Minister. A separate core group comprising the Planning Division, key officials of the MoH, National Planning Commission, Ministry of Finance, EDPs and private and health related professional organisations was tasked to produce a coherent Nepal Health Sector Strategy.

The outcome of this work was the recently approval by the MoH of the Nepal Health

Sector Strategy – An Agenda for Change, June 2002. Currently a Programme

Preparation Team has been formed to prepare a fully costed Nepal Health Sector

Programme – Implementation Plan.

The time frame for donor commitments to this programme implementation plan is Spring 2003 and operationalisation of the plan in the next Nepal fiscal year beginning July 2003.

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The Millennium Development Goals (MDGs) are a set of goals and targets for monitoring human development. They are centred around 8 main goals and 18 targets: 1. Eradicate poverty & hunger; 2. Achieve universal primary education; 3. Promote gender equality and empower women; 4. Reduce child mortality; 5. Improve maternal health; 6. Combat HIV/AIDS, malaria and other diseases; 7. Ensure environmental sustainability; 8. Develop a global partnership for development

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The Nepal Health Sector Strategy - An Agenda for Change

The recently published Health Sector Strategy document is the current central guiding document arising from the sectoral reform discussions in Nepal over the past 3 years. HMG have set three programme outputs and five sector management outputs which will be the core of the reform programme over the next 5 years. These are:

Programme Outputs:

1. EHCS package: The priority elements of an Essential Health Care Service –

safe motherhood and family planning, child health, control of communicable disease, strengthened out patient care – will be costed, allocated the necessary resources and implemented. Clear systems will be in place to ensure that the poor and vulnerable have priority for access.

2. Decentralisation: Local bodies will be responsible and capable of managing

health facilities in a participative, accountable and transparent way with effective support from the MoH and its sector partners.

3. Public-private mix: The role of the private sector and NGOs in the delivery

of health services will be recognised and developed with participative representation at all levels. Clear systems will be in place to ensure consumers get access to cost effective high quality services that offer value for money.

Sector Management Outputs:

1. There will be coordinated and consistent Sector Management (planning, programming, budgeting, financing and performance management) in place within the MoH to support decentralised service delivery with the involvement of the NGO and private sectors.

2. Sustainable development of health financing and resource allocation across the whole sector including alternative financing schemes will be in place

3. A structure and systems will be established and resources allocated within the MoH for the effective management of physical assets and procurement and distribution of drugs, supplies and equipment.

4. Clear and effective Human Resource Development policies, planning systems and programmes will be in place.

5. A comprehensive and integrated management information system for the whole health sector will be designed and implemented at all levels

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NTP and the current security situation

Over recent years there has been escalating violence between Maoist groups and the government. Originating in the remote hill districts this violence has extended throughout the country causing significant disruption to civil life and the delivery of government services. Unofficial sources would suggest that upward of 70% of the country is controlled by Maoist forces. Government control backed by security personnel is confined to Kathmandu, main municipalities, the easily accessible areas of the terai and the district headquarters in hill and mountain areas. The consequential political and security environment has major implications for the health sector and TB control. Key issues are:

x The government has this year revised budget allocations and diverted social sector spending to the military and security forces.

x There is increasing anecdotal evidence of accelerated migration from Maoist controlled hill areas to urban and peri-urban locations in the major valleys and the terai.

x Movement of food and medical supplies within districts has been hampered by activities of the Maoists or the security forces.

x Primary Health Care delivery outside of district centres in remote areas has been greatly hampered. Staff vacancies have increased and medical supplies depleted. As the TB control programme is dependant on a functioning PHC system for diagnosis and treatment in hill areas it is expected that programme outcomes will be adversely affected. In terai and municipality areas the increased migration will place additional strain on stretched urban services. Increased poverty and poor nutrition combined with psychological stresses is likely to increase the breakdown from infection to TB disease in the population. The potential responses to the situation are discussed later.

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The National Tuberculosis Control Programme

Background

The first organized attempts to control TB in Nepal began in 1934 with the construction of the Tokha sanatorium. A Central Chest Clinic (CCC) was established in 1951 to provide curative TB services including free treatment for the poor. In 1985 the TB Control Project (TBCP) was established and in the same year Short Course Chemotherapy (SCC) was introduced in some parts of country mainly by the non-governmental organizations working in TB control.

In 1989, the National TB Programme (NTP) replaced the TBCP and the National

Tuberculosis Centre replaced the Central Chest Clinic. In 1993 SCC was adopted as

the national drug regimen for tuberculosis treatment by the NTP. Following a joint HMG/WHO review of the NTP in 1994, a 5 year plan based on the WHO framework for effective TB control, with a policy of Directly Observed Treatment Short course (DOTS) was prepared, and approved by HMG in August 1995. The joint team concluded that only 30% of infectious cases at that time were being registered in the NTP, and only 40% of these cases completed treatment.

The government identified TB as one of its top ten priorities in the 8th and 9th year health plans. DOTS was introduced into four demonstration centers in April 1996 and expanded throughout the country in the following 5 years. By July 2001, DOTS was being delivered through 227 treatment centres with 684 sub-centres and covered 84% of the population, across all 75 districts.

NTP Objectives

x 85% cure rate in new smear-positive pulmonary tuberculosis cases

x 70% case detection ratio in new smear-positive pulmonary tuberculosis cases x Directly Observed Treatment, Short Course (DOTS) available in all 75 districts of

the country through the NTP

x By the end of the Tenth Fiscal Year Plan all the patients should be treated under DOTS strategy

NTP Strategies

x Gradual expansion of DOTS throughout the country

x Establish a treatment centre with microscopy facilities for every 40,000- 100,000 population, with sub-centres as required.

x Promote early detection of infectious pulmonary cases on the basis of sputum smear examination.

Major NTP Policies

x The basic unit of the NTP for diagnosis and treatment is the district hospital and primary health care centre.

x All centres offering TB treatment must utilise the standardised regimens of short course chemotherapy (SCC) adopted by the NTP, with Directly Observed Treatment, Short Course (DOTS).

x Free anti-tuberculosis treatment to all patients with active tuberculosis, through the basic health services, with a priority for sputum smear-positive cases, in every district of the country

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x Evaluation by four monthly cohort analysis of treatment outcome x Community involvement for DOTS implementation

NTP Activities

x Establish a national network of microscopy centres, and a system for ensuring quality of sputum smear examination

x Organise treatment delivery and supervision of programme activities through the general health services of the country, in an integrated way x Ensure continuous drug supply and monitor the quality of drugs. x Maintain a standard system of recording and reporting in line with the

integrated Health Management Information System of the department of health services

x Monitor the results of treatment and evaluate progress of the programme by means of 4-monthly cohort analysis

x Develop and maintain the skills of health workers by providing training. x Promote involvement of the community in the NTP.

x Strengthen co-operation between NGOs and development partners involved in the NTP

x Co-ordinate NTP activities with other PHC activities carried out in the country, especially leprosy and AIDS/STD programmes

x Conduct relevant research to improve the effectiveness of the NTP.

NTP Organisation

At the national level the National Tuberculosis Center is the central unit of the NTP. The Director of the NTC manages the National Tuberculosis Centre and National Tuberculosis Programme. NTC staff provide technical support to the field programme as well as running the NTC referral clinic and laboratory. The Regional Tuberculosis

Centre (RTC) in Pokhara provides a focus for technical support in the Western

Region.

At the regional level, all activities are carried out with the co-operation of the 5 Regional Health Services Directorates. Regional tuberculosis/leprosy assistants (RTLA) support the Regional Health Services Directorate in managing TB control activities in the region.

At the district level, the district health officer (DHO) is responsible to plan and implement NTP activities. A district tuberculosis/leprosy assistant (DTLA) supports the DHO in the management of TB control activities. Within the district, the basic unit for diagnosis and treatment of patients with tuberculosis is the district hospital and the primary health centre. Diagnostic and treatment services will not usually be provided lower than this level, though health posts may act as sub-centres for supervision of patients on DOTS.

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Organisational Chart of the NTP

Co-ordination of the NTP within the health services Technical policies for the NTP Planning, Monitoring and Evaluation Training, Supervision and Research Management of the NTP at the Regional Level

Training and Supervision Monitoring

Management of the NTP at the District Level

Diagnosis, tratment and Monitoring

Case Holding and Treatment

Case Holding / Tracing

Ministry of Health Director General of Health Services

National Tuberculosis Programme/

National Tuberculosis Centre, Director Other National

Centres & Divisions of DOH Regional Directors RTC/RTLA District Health Officers DTLA Primary Health Centres

Sub Health Posts

NCASC PFAD NPHL EDCD NHTC LMD NHEICC HRDD AIDS Centre CHD FHD KEY Main Structure of NTP Line Management Technical Supervision Responsibilities Health post DOTS committee NGOs Communities Logistics

NTC is responsible for national estimates and procurement of anti-tuberculosis drugs. The central store of anti-tuberculosis drugs is located in the NTC. Drugs are

distributed from the NTC with support of the Logistics and Management Division (LMD). At the regional level supporting INGOs (Eastern, Central, Mid Western and Far Western Regions) and RTC (Western Region) manage drug supply from the central store up to the district with close cooperation of LMD and the Regional Medical Stores (RMS). Logistic below the district is managed by the respective DHO (with assistance from the supporting INGOs if required).

Agencies supporting the NTP

Bilateral and multi-lateral agencies, INGOs, NGOs and research institutions together provide substantial support with financial assistance, technical assistance, materials in kind, diagnostic and treatment services, research and management capacity.

Norwegian Aid (NORAD) has been supplying anti tuberculosis drugs to the NTP for the last two years. The Norwegian Heart and Lung Association (LHL) has supported the NTP through the provision of funds for supervision, training, research, supply of anti- tuberculosis drugs and the NTP annual review programme.

TheDepartment for International Development (DfID), UK, is currently providing

anti-TB drugs and manpower support channelled through WHO for a five year period.

The Japan International Co-operation Agency (JICA) supported the construction

of the NTC and RTC buildings in Thimi and Pokhara, TB activities in the Western region, the supply of anti-tuberculosis drugs, logistic management system development and technical support at the national level. JICA has also contributed to the development of the TB microscopy and quality control network. Currently JICA are supporting an urban TB control programme through their Community TB and

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TheWorld Health Organisation (WHO) supports the NTP through the provision of staff and funding for training courses, attendance at international conferences and research into multi-drug resistance & HIV-TB.

The International Union Against TB and Lung Disease (IUATLD) provides

technical support and consultancy to the national programme.

The SAARC Tuberculosis Centre (STC) is physically located within the NTC

building and has organized several regional training courses in Nepal over the last five years.

The Britain Nepal Medical Trust (BNMT) supports TB services in the Eastern

region through training, supervision and drug logistics.

The International Nepal Fellowship's Tuberculosis Leprosy Programme (INF

TLP) supports government tuberculosis services in the Mid-West region through training, supervision, laboratory quality control, and logistic supply. In addition, TLP runs four referral clinics in Nepalgunj, Ghorahi, Surkhet and Jumla.

The Netherlands Leprosy Relief Association operates in the Far West region

supporting the NTP through drug supply, laboratory quality control, training and supervision.

The United Mission to Nepal (UMN) provides TB services in all of its general

hospitals including the Tansen hospital which is one of the largest TB diagnostic centres in the country. In addition, UMN has provided support to HIV-related counselling for TB patients.

The German Nepal TB Project (GENETUP) is supporting TB control activities in

Kathmandu, Bara, Parsa, Rautahat, Sarlahi and Mahottari.

The Nuffield Institute for Health, UK, is involved in technical support for research

into the adaptation of DOTS to suit the mountainous areas of Nepal and also into building links between the private sector and the NTP.

TheNepal Anti-TB Association (NATA) plays an important role in controlling TB.

It has health education activities at district level, and also provides treatment services in 7 districts.

Quality control system for sputum smear microscopy

A quality control (QC) system for sputum smear microscopy was implemented in Nepal in 1996 coinciding with the start of DOTS implementation. Currently there are 5 Regional Quality Control Centres with trained quality control assessors (QCA) who carry out quality control on a quarterly basis.

Research

Two international collaborating centres support TB related research projects in Nepal. These are the Nuffield Institute of Health (UK) and the Research Institute of TB

(RIT) in Tokyo, Japan. Current research includes: i

i

i i

i

Family based DOTS and Community based DOTS. A Randomised Controlled Trial (RCT) to identify appropriate tuberculosis treatment delivery strategy in hard to access areas (10 hill districts) of Nepal, where institution based DOTS is not feasible to all TB patients.

Pilot research to link private practitioners and NGOs with the NTP, to ensure that all patients receive a high standard of care and their results are reported.

Drug resistant surveillance survey with participating sites across the country. The provision of voluntary HIV testing is being piloted in 5 major diagnostic TB centres.

An Adult Lung Health Initiative international study to develop guidelines for the management of respiratory symptomatics attending primary health care facilities is underway in 2 districts.

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Lessons for the Nepal Health Sector

What lessons can be drawn both positive and negative from the experiences of the TB control programme in Nepal? In the eyes of many it has been a success story but what are the learning points for other programmes and the future development of the health sector? This section looks to provide insights of value to non-TB programmes while the later section ‘Lessons for the Region’ seeks to highlight issues for other TB

programmes in the region. Technical aspects of TB control are therefore addressed in

the later section while this section concentrates on generic issues of programme

management, organisational culture and implementation. The section concludes

by considering the implications of health sector reform (HSR) on the TB programme, and asks how the TB programme might assist or hinder the current reform process in Nepal.

Leadership

A consistent theme which arose in interviews was the impact of the NTC Director’s leadership of the programme as a key success factor. He has clearly earned the respect of his staff and they are motivated by his action-oriented leadership style. The NTP has been fortunate to have had a number of motivational senior staff associated with it who have all contributed to the leadership success of the programme. The lesson is that leadership is vital for success and should consist of:

x Consistency – the value of retaining a good director in the same programme for a

prolonged period of time

x Quality – good leaders should be identified and equipped with the necessary

technical and managerial training for their task.9

x Reach – to gain respect of staff and a clear understanding of the programme the

leader must be prepared to make many field trips.

x Delegated responsibility – within the NTC tasks have been clearly defined and

delegated. This reduced the inefficiencies often seen in health programmes when all decisions are referred up to the director.

x Example – Dr Bam and his senior officers work hard and long hours and demand

the same of their staff. Demonstrating a positive work ethic can diffuse throughout the programme.

Strong team approach

Under-girding the leadership was a strong, motivated and technically capable team consisting of the NTC staff, the regional and district level supervisors, the officers of the various implementing INGOs and significantly, the Nepal WHO TB Medical Officer. It should be emphasised that it was the particular synergy of the central level team at NTC, the WHO medical officer and the NTP Director that together provided the impetus and direction for the programme in the mid to late 90s.

Staff motivation

At central and district level there was a general impression that staff enjoyed their work and were able to make a difference. Empowered staff are a powerful driver for success and innovative implementation. Evidence of commitment and enthusiasm for DOTS was also described at the local health post level. The key issues identified were:

9

In Dr Bam’s case he benefited from training in TB control and epidemiology at the Research Institute of Tuberculosis in Japan.

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x Staff saw the DOTS approach produce results which re-enforced job satisfaction

x Staff were trained,equipped and motivated

x The JICA RIT training programme has provided excellent technical and programme management training for successive cohorts of TB staff.

x The LHL funding has emphasised the requirements of quality technical training

and supervision at all levels.

x Peer-led monitoring and evaluation – this is discussed below.

x The national & international recognition of the Nepal TB programme through

the honouring of Dr Bam with various awards brought a significant moral boost

to all staff working for the programme.

Communication

Compared with other programmes the NTP displays a culture of wide and open communication. This communication is:

x Upward communication – in the form of advocacy, and awareness-raising to

senior government staff, politicians and the international TB donor community.

x Outward communication – in the form of widespread proactive media

reporting, health education activity to communities, and a wide range of tailored

training programmes for health care workers and social action groups.

x Inward communication – across all cadres of health care staff working in TB

control. This has created a shared vision and clarity of purpose using the DOTS strategy.

Peer review

Closely linked to communication and staff motivation is the regularised practise of

‘peer based review’ for staff working in TB control. This quality improvement

process can be seen throughout the programme:

x International – by means of the IUATLD technical consultancy field visits

funded by LHL and the annual national review process. By ensuring one external expert joins each regional field team the local managers are exposed to international technical expertise in programme evaluation.

x Regional (Asia)- The development of the annual South-East Asia Regional NTP

Managers Meeting provided a platform for national NTP managers to be held accountable to their peers in the Region. Nepal as host country for the meetings benefited from the extra pressure of having its programme ‘on show’ and being able to include more NTP staff as observers or participants.

x National – by means of the trimesterly meeting of the Regional TB/Leprosy

Assistants to review the last trimester’s data and plan for the future. In addition, most years there have been large national TB seminars held at NTC which have afforded District Health Officers the opportunity to meet and discuss their local TB control efforts.

x Regional, district, and treatment centre trimesterly reviews – at each level of

responsibility the programme has instituted review meetings to generate and analyse the cohort report for the last trimester and be accountable for local programme performance. This greatly increases ownership of data, problems and ultimately local solutions. Indeed the emphasis of these meetings is identify and solve problems locally.

Sharing of best practice

The quarterly cohort reporting schedule and associated technical peer review meetings are the vehicle through which district, regional and national planning is

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discussed and shared. However staff interviewed also highlighted the value of other means of sharing best practice across the programme:

x Observational visits – permit staff to visit ‘model DOTS’ programmes in other

areas to share their own experiences and pick up new approaches that may be introduced in their own treatment centres.

x SAARC, IUATLD and WHO seminars and training events – The Nepal

programme has been most fortunate to regularly host international training

programmes and as a result national staff have benefited from the opportunity to

attend and learn from TB technical staff working across SE Asia.

Central policy – local innovation

The NTP is a good example of a technical programme which operates according to a clear national policy yet encourages local application of the model. The key features of this success factor are:

x Central features

o National adoption of an evidence-based strategy (DOTS Strategy)

o Documentation of a policy framework and national implementation manual (NTP manual) in Nepali as well as English language

o Training materials in Nepali prepared for each cadre of staff

o Strong emphasis on recording and reporting of programme outcomes

x Local innovation - a number of witnessed examples are listed to demonstrate the

diversity of initiatives taken to apply the basic tenets of the DOTS strategy:

o A private nursing home in Lalitpur (Hargans Nursing Home) decided to provide a daily rice meal to several homeless patients with TB to encourage their regular attendance for directly-observed outpatient treatment of their TB.

o The UMN Yala Urban Health Programme (YUHP) has developed links that permit access to local carpet factories to seek out workers with TB. The programme has also trained ward/tole level volunteers who will carry sick patients to the clinic daily.

o TheINGOs are encouraged to develop local strategies to meet local needs

such as the INF ‘default tracers’ attached to the Nepalganj Clinic.

o BNMT has provided 'hostel facilities' at a district centre to those who are unable to attend the DOTS clinic on a daily basis in a hill district of eastern Nepal (Dhankuta).

High quality technical support

A theme raised by interviewees as a reason for the particular success of the

programme was the consistent high quality technical assistance available to the NTP over the previous decade. Of note were both the quality of the technical assistance

and the generally positive nature of relationships between the NTP and technical assisting agencies. This particular feature of the NTP is multifaceted and has been

additive through the 1990s. Indeed certain reviewers went as far as to suggest that the

INGOs contribution has been the backbone of the TB control programme in Nepal. The chronological development was as follows:

x Central assistance from JICAandJATtechnical assistance to NTC and RTC x District and regional assistance from technically focused INGOs such as

GENETUP, INF, UMN, BNMT and NLR.

x The TB related NGO collaboration which later became formalised as the TB Control Network (TBCN)

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x The recruitment of Ian Smith as the first WHO TB Medical Officer who not only drafted the initial plan but also was integral to the implementation of the first 5 year development plan

x The impact of the annual external technical reviews

x The development of the annual TBnet conferences hosted by NTC x The increasing impact of the SAARC TB Centre

x Nepal as host to the WHO/IUATLD Asia TB Programme Managers’ Training

Focused and consistent external donors

The funding of the NTP resource envelope is discussed in greater depth later in the report but the key success features are:

x Thecontinuity of the donor partners

x Thein-country presence of many of the donor agencies

x The opportunity for donors to meet annually at the Technical Advisory Group

(TAG) meetings

Partnership working

The past 5 years have witnessed major expansion of partnership working to deliver the DOTS strategy across health institutions and civil society. Now DOTS is administered through partnerships with:

x Academic institutions and private medical colleges x Tertiary, regional and NGO operated hospitals x INGO regional counterparts

x Private nursing homes x NGOs such as NATA

x DOTS committees formed at the treatment facility level.10

x CBOs such as womens groups responsible for a DOTS treatment centre

x The media – although not actually acting as a delivery point for DOT are a major partner in the awareness raising component of the NTP strategy.

Appropriate and phased decentralisation

Decentralisation is a significant platform of the HSR process and therefore it is interesting to review the NTP from this perspective. Some commentators felt that the NTP has not been particularly active in the decentralisation process however we would disagree and point to the following positive developments in this area:

x The creation of the DTLA posts in every district was a major pillar in the decentralisation of supervision and associated district level NTP functions within the District Health Office.

x There is evidence that the decentralisation of functions has been measured and responsive to the strength or weakness of the supporting technical or managerial structure. Thus logistics management was only partially decentralised to the regional INGOs as drug supply was seen as critical to the success of DOT. More recently however active plans have been made to pass responsibility to Regional Medical Stores and provide the required technical support to maintain an uninterrupted supply chain.

x With the recruitment of RTLAs and DTLAs into government service the implementing INGOs were able to provide counterpart staff to work alongside the

10

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DTLAs in the District Health Offices. This enabled the fast transfer of knowledge, skills and attitudes in TB control from the INGO staff to the government staff.

The formation of action – orientated, structured networks

As a natural outworking of the above organisational culture of communication, peer support and partnership working, networks emerged which grew through the mid-1990s to become significant models for public health at a Regional and national level. Three examples of these are:

x TBCN – the TB Control Network. This arose from a desire by the in-country implementing INGOs, the leader of the JICA JAT, and NATA to agree on case definitions, reporting mechanisms and shared health promotion activities. This expanded into a national group with documented group values, procedures and functions. The meetings were soon hosted at NTC and attracted a widespread commitment from agencies involved in the delivery of TB services across the country. When the development plan was launched in late 1994 this group had already worked through the ‘forming, storming, norming’ stages of group development and reached a high level of ‘performing’11. It provided the NTP with the ideal platform for the required change management process necessary to implement all the enhanced features embedded in the TB development plan. Interestingly the TBCN became a model for a similar group set up by the counterpart INGOs working in the Leprosy field in Nepal.

x TBNet – in many ways TB-net grew from the principles of the TBCN. TBNet

originated from a meeting sponsored by the TEAR Fund UK evaluation unit to bring together NGOs that it supported throughout the south-asia region in 1992. The purpose was to identify model programmes and generate a guidance document. The experience of sharing ideas, supporting one another and making contacts across the region was so stimulating that the principle of a annual meeting, hosted in Kathmandu grew to become a much larger staged event and attracted global attention for its impact on TB action. The focus was on strengthening the capacity of the NGOs working in TB control and to be an independent, informal participative network using email, a website, published documents and an annual 2 day TBNet Conference as the means of shared communication. The steering committee was mostly composed of TB related professionals working in Nepal and so Nepal became the natural locus of TB information, training and activity. TBNet was probably one of the factors that brought the annual WHO/IUATLD TB programme managers training to Nepal. TBNet has now been absorbed into the STOP TB Partnership and many of the principles of the original group can now be seen in the workings of STOP TB at a global level.

x DOTS committees – while TBNet was a network that quickly expanded its

impact outwards across the Region, the introduction of local DOTS committees is an example of the same principles applied at the grass roots of treatment delivery. These committees are formed, trained and sparked with enthusiasm to act as a local community based accountability mechanism for DOTS treatment centres. Membership seeks to cross the public, political, NGO and CBO spectrum of the locality. While not all are equally active there are some pathfinder examples of well functioning DOTS Committees.

11

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Summary of key ‘success factors’

The matrix below seeks to summarise the success factors identified in the operation of the Nepal TB programme. The allocation of the tick marks is highly subjective and various combinations could be constructed. However the key message is that three skill areas are required – interpersonal,technical and administrative. We believed that the most critical skill is that of interpersonal communication and that technical and administrative capacity are required in equal measure for the successful implementation of a programme.

Skill areas required Success Factors

Interpersonal Technical Administrative

1. Leadership

3

2. Strong team approach

₃

3. Staff motivation

3

4. Communication

3

5. Peer review

₃

6. Sharing of best practice

3

7. Strong central policy with local innovation

3

8. Quality technical support

3

9. Focused and consistent external donors

3

10. Partnership working

₃

11. Appropriate & phased decentralisation

3

12. Action-oriented

structured networks

3

Table 5: Success factors and skill areas

Negative factors

Not all those interviewed were convinced of the ‘success’ of the Nepal TB programme. Issues of concern or alternative perspectives were raised. These are discussed below:

Success

Administrative skills Technical skills

Interpersonal skills

x “Successful but not a model” – it was suggested to the author that TB control as

a public health programme is technically straightforward to implement – narrow case definition, evidence-based treatment protocols, delivered through primary care setting. And when combined with the fortuitous state of charismatic and consistent leadership, high quality external technical assistance and a solid external donor support base much more should have been delivered by the programme than is apparent.