The development of tuberculosis control in Bangladesh has taken place in the context of a large sector-wide approach to health sector development (HSD), with significant involvement from international aid agencies in shaping the HSD process. Effective TB control is seen as a priority, given the potential scale of the problem, the growing threat of HIV, the population density, and the generally high level of poverty.
Partnership with NGOs
The Government of Bangladesh is committed to nationwide coverage of TB services through the significant involvement of local nongovernmental organizations (NGOs) in the delivery of selected services. NGO partnerships with organi-zations such as the Bangladesh Rural Advan-cement Committee (BRAC) and the Damien Foundation already serve 40% of the 110 million people covered at present. The direct partnership of NGOs in the delivery of TB services in Bangladesh has enhanced case-finding and treatment supervision through community participation.
This approach is gender sensitive, cost-effective, and supportive of patient needs. The creation of additional partnerships will be an important requirement for continued expansion in coverage and the fight against TB. One new group of partners is the private sector health care community, who have influence in shaping public opinion and treatment practices in Bangladesh.Their effective involvement in the national programme will help especially with services that are neede for the four major urban areas where private health services are strongly present. Social mobilization strategies are needed to stimulate demand for effective treatment.
Major international partnerships include the World Health Organization (WHO), the United Nations Children''s Fund (UNICEF), the International Labour Organisation (ILO) for workplace activities, the World Food Programme (WFP), the United States Agency for International Development (USAID) contractors, the International Centre for Diarrhoeal Disease Research (ICDDR), and the Research Institute of TB (Tokyo). The World Bank supports the Bangladesh 1998-2003 Health and Population Sector Programme (HPSP).
Health Sector Reform
Health Sector Reform has provided an opportunity to strengthen TB control and enhance the contribution of the service to national development through appropriate cost saving and delivery efficiencies. For example, the National TB Programme has been integrated with the Leprosy Elimination Programme and now forms a key component of the Essential Services Package (ESP) developed as part of the sector-wide health reform process.
The benefits of integration include better use of shared activities such as training, surveillance, reporting, monitoring, and Information- Education-Communica-tion (IEC). The inclusion of TB control in the ESP will greatly expand access to TB treatment.
Challenges
Challenges include extending partnerships to the private health care sector to ensure standardization of treatment. Private health care is a significant provider of services and the implementation of DOTS within the system is vital. Special efforts will be needed to establish TB control suitable for large metropolitan cities.
Expanding the budget for TB control is paramount. At present, the TB budget is US$ 1.46 million, but projections identify a need for US$ 20-25 million up to 2005 to achieve full TB control. Another important challenge is dealing with the very high HIV/AIDS rates among specific high-risk groups. On the operational side, drug procurement procedures and quality control of laboratory services need considerable strengthening. Reinforcement of the NGO network to more effectively reach the TB control needs of women presents an additional challenge.
Successes and lessons learned
TB, along with leprosy, is integrated into the Government''s ESP for national health development, ensuring the appropriate prioritization of TB within a sector-wide approach to health development. Reform has created positive opportunities for TB to integrate with other delivery systems. The successful involvement of local NGOs and other partners has been vital to expand coverage.
NGOs in Bangladesh have demonstrated that even in poor countries with relatively low literacy and educational levels, communities can be mobilized as effective partners for DOTS delivery. Partnership expansion maximizes results. Successful partnership with NGOs requires good technical services support to ensure quality and effectiveness.
Future needs and major priorities
- Budget projections: US$ 20-25 million (2000-2005).
- Technical Assistance:
- Management and supervisory capacity building;
- Social mobilization to stimulate demand;
- National reference laboratory;
- TB drug-resistance surveillance;
- Training curriculum review.
- Metropolitan area expansion.
- Behaviour change communication strategy.
- Microscopy quality control system at peripheral level.
- Operational research:optimizing TBcontrol within reforming health system.