Tuberculosis under the control of family doctors
Author: Yana Kazmyrenko, Ukraine
Odessa became the first city in Ukraine to introduce the ambulatory TB care model and started giving bonuses to health workers for detecting and supporting patients.
At the cutting edge of implementing TB programmes
Ukraine is one of the Top 10 countries with the biggest burden of tuberculosis. It also ranks second in the world in terms of the number of patients with drug-resistant forms of TB, which cannot be treated with standard regimens. As reported by the Public Health Centre of Ukraine, Odessa region is the absolute leader in terms of the number of TB patients in the country: 140 cases per 100 thousand people.
Oksana Leonenko-Brodetskaya, doctor of the 1st City TB Treatment Clinic, says that these sad statistic numbers reflect the good quality of their work. The more patients with TB are diagnosed, the more people can timely access to the therapy.
Fortunately, today Odessa is at the cutting edge of implementing TB programmes. For over a year, TB doctors here work within the Fast-Track Cities Project since the city joined the #ZeroTBCities initiative. A targeted municipal programme to fight HIV/AIDS, tuberculosis, and viral hepatitis “Fast-Track Odessa” is implemented was approved for 2018-2020. Thus, for example, after two weeks of treatment patients are not considered dangerous for other people and can receive their TB medications in family clinics.
Thanks to those initiatives, in 2018 the number of people with newly diagnosed TB grew from 1,113 (in 2017) to 1,245 persons, with treatment success rate for drug-sensitive TB increasing from 56% to 77%.
Currently, Odessa is transitioning to the state funding: the Global Fund is withdrawing from Ukraine and all the programmes will be funded from the state budget.
Bonuses for health workers, food for patients
To increase the efficiency of TB diagnostics and care, Odessa municipal authorities made a decision to pay doctors two thousand hryvnias for every patient they detect in their district.
Compensation is paid after a special commission proves that all the doctor’s actions were in line with the relevant guidelines.
“At first, only doctors were supposed to get the bonuses, but later we realized that nurses also should receive them as they are the ones who are searching for patients and supporting them. As a result, about 80 nurses now receive additional bonuses of a thousand hryvnias for providing support to every patient with TB,” explains Oksana Leonenko-Brodetskaya.
There are also incentives for patients: if they take their medications for 23 days with no interruptions, they receive bonus cards, which can be exchanged for food products in supermarkets.
Besides, health professionals have high expectations related to the launch of sputum collection sites in 11 primary health care centres, which will allow improving the efficiency of diagnostics.
Migrants and homeless people are the most difficult to treat
TB incidence rate in this city located at the coast of the Black Sea is still growing due to a high number of homeless people and internal migrants, who come to Odessa for living or working in summer season.
“The issue of homeless people is to be resolved at the national level. We can diagnose TB and prescribe treatment regimens, but no one knows where to find such type of patients the next day,” says Oksana Leonenko-Brodetskaya.
Nevertheless, this category of patients is not forgotten. In Odessa, there is a doctor and a nurse, who meet homeless people when they are released from hospital. They support such patients and control how they take their medicines in the places where it is convenient for the patients: at gas stations, in street markets or in parks.
In other regions, which also implemented the pilot projects to introduce ambulatory care, there were suggestions to open residential facilities for homeless people, which would allow to provide follow-up support to the patients who have no place to live.
People with HIV prefer to receive treatment in inpatient units
Transition to the ambulatory care brought some unexpected insights: it turned out that most HIV-positive patients with tuberculosis refuse to receive treatment at the offices of family doctors. They insisted that they would like to continue treatment in inpatient facilities to make sure that their family members or neighbours would not accidently learn about their diagnosis.
The rate of co-infections in Odessa is also one of the highest in Ukraine. While in other regions 18% of patients have HIV/TB co-infections, in Odessa the rate of such co-infections in 2018 was as high as 50.6%.
“Most Odessa residents learn about their HIV status in the municipal TB treatment clinic: in 2018, out of 630 patients with HIV, more than 400 learned about their diagnosis at our clinic. The clinic turned into a multifunctional treatment facility: we do most of tests and our doctors prescribe therapy for any diseases. Some people have to receive treatment for 2-3 infections – tuberculosis, HIV, hepatitis,” adds Oksana Leonenko-Brodetskaya.
How Ukraine can ensure transition to the ambulatory care
When transition of Ukraine to the ambulatory care is going to take place is so far an open question. At the national level, bonuses to family doctors for diagnosing and treating patients with TB will be paid by the National Health Service.
Andrey Aleksandrin, head of the Infection Control in Ukraine NGO thinks that most doctors and nurses from primary health care facilities are not ready for working with TB patients yet.
However, the biggest challenge is to change the stereotypes associated with TB, with people thinking that the best way to defeat the disease is to isolate patients in hospitals.
Ukrainians do not realize that the hospitals, where TB patients live for years, are a danger on their own.
“In the process of inpatient treatment in such hospitals, patients exchange their bacteria and develop drug-resistant forms of TB. Moreover, in our country we do not have any inpatients units, which would fully comply with the infection control standards,” sums up Andrey Aleksandrin.
According to the expert, two weeks on inpatient treatment are enough for most patients to ensure that they do not transmit bacteria to people around them. Ambulatory treatment allows them to maintain their usual lifestyle and retain their employment.