1. Health system assessments
Has DOTS expansion reached its limits through existing health systems?
Christy Hanson
WHO Geneva

2. Health system assessments
Aims:
Enhance DOTS expansion efforts by tapping into underutilized strengths of the existing health system
Recognizing and addressing limitations of the health system in supporting DOTS expansion
Enhancing the contribution of DOTS expansion to the aims of health systems strengthening
Promote complementarity
Application:
Planning within NTP
Global lessons learned
Partners Forum

3. System aspects explored
Infrastructure
Coverage of health facilities by type / capacity
Public and private sectors
Human resources
Distribution
Activities by cadre
Training
Monitoring mechanisms
Supplies / logistics
Funding
Planning

4. Measuring DOTS coverage

5. DOTS coverage within limited PHC
Ethiopia
DOTS coverage within limited PHC
45% of rural population within walking distance from PHC facility
85% of pop. lives in rural
Wide regional variance in facilities per population
33% have access to safe water
45% live on <US$1 / day
30% of existing facilities implementing DOTS

6. DOTS Coverage within strong PHC
Vietnam
DOTS Coverage within strong PHC
11% of population in areas with limited geographical access to PHC
North / south variance: human resources
Hospital use:
36% of users from highest income quintile
8% from lowest income quintile

7. Where the system provides DOTS
Kenya
Where patients go vs.
Where the system provides DOTS

8. Private sector
Overall: limited awareness of the role or magnitude of private sector, limited engagement in TB control
Ethiopia:limited but exists, pharmacies, hospitals
Kenya: almost equal use of public and private providers as entry point
Pakistan: 40% of health care provided by private sector
79% of TB patients seek care initially in private sector
Vietnam: 60% of outpatient visits with private clinics

9. Kenya
Human resources
300 trained clinical officers unemployed

10. Human resources: distribution
Ethiopia
Human resources: distribution

11. Human resources: distribution
Nigeria
Human resources: distribution

12. Human Resources: Training
Vietnam: systematic training for TB
10,000 general health workers / year
Training not integrated in other general health training
No examples of TB integrated within pre-service training
No examples of NTP involvement in general PHC in-service training
Kenya: TB training of clinical officers stopped
Nigeria: States responsible for training own staff in PHC
NTP supports state training of 60 workers / year
Pakistan: training lady health workers for TB
Ethiopia: New cadre of health workers to be trained / deployed at most decentralized level (PHC)

13. Human resources involved in TB control
Vietnam
Human resources involved in TB control
Total: 15,772 staff involved in TB control

14. Decentralization issues
Increased decision-making and budget authority at decentralized levels
Variable levels of political commitment to TB
Variable resources to invest in TB
Shifting of resources (human, financial)
Ethiopia: process
Nigeria: release of funds, planning
Vietnam: poor provinces, less to invest in health
Pakistan:

15. High costs for patients
Nigeria: 70% of health expenditures private, mostly out-of-pocket
Kenya: cost-recovery in 68% of public facilities
Vietnam: 80% of health expenditures - direct household spending
Per capita household spending US$20
Documented wealth inequalities in utilization of services: Kenya, Vietnam

16. TB compared to other disease control programmes
Coverage
Kenya: immunization services in 80% of public facilities, reproductive health in 75% of facilities
TB control in 30% of public facilities
Ethiopia: leprosy has broader coverage than TB
Drug supplies: TB supplies generally more stable than other essential drugs

17. Summary
Has DOTS Expansion reached its limits through existing health systems?
Strengths
Integrated lab networks
Stable drug supplies
Challenges
Political commitment at decentralized levels
Utilizing and building capacity of PHC
Recognizing types of facilities and workers, tailoring NTP
Engaging private sector and pharmacies
Training
Limited coverage of PHC in some countries

18. Discussion
Any messages that would be useful to bring to Partners Forum?