32926 WORLD BANK WORKING PAPER NO. 56
Stopping Tuberculosis in Public Disclosure Authorized Central Asia Priorities for Action
Joana Godinho Jaap Veen Masoud Dara James Cercone Public Disclosure Authorized José Pacheco Public Disclosure Authorized Public Disclosure Authorized THE WORLD BANK
WORLD BANK WORKING PAPER NO. 56
Stopping Tuberculosis in Central Asia Priorities for Action
Joana Godinho Jaap Veen Masoud Dara James Cercone José Pacheco
THE WORLD BANK Washington, D.C. Copyright © 2005 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First Printing: June 2005
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ISBN-10: 0-8213-6276-3 ISBN-13: 978-0-8213-6276-1 eISBN: 0-8213-6277-1 ISSN: 1726-5878 DOI: 10.1596/978-0-8213-6276-1
Joana Godinho is a Senior Health Specialist at the Human Development Department of the World Bank. Jaap Veen is Coordinator of the Europe Unit of the KNVC Tuberculosis Association. Masoud Dara is a TB Specialist at the KNVC Tuberculosis Association. James Cercone is an Economist and President of SANIGEST. José Pacheco is an Economist at SANIGEST.
Photo by Jaap Veen: Previously mobile, but still functional X-ray unit operates in Central Asia.
Library of Congress Cataloging-in-Publication Data has been requested. Contents
Acknowledgments xi
Acronyms and Abbreviations xiii
Executive Summary xv
Part I: Priorities for Action
1 Introduction 3 The Global TB Epidemic 6 TB in the Former Soviet Union 8 TB in Prisons 10 TB Control in the Former Soviet Union 12
2 Tuberculosis in Central Asia 17 Epidemiology of TB in Central Asia 22 TB Control in Central Asia 32
3 Main Findings and Key Actions to Stop TB in Central Asia 57 Main Epidemiological Issues 57 DOTS Implementation in Central Asia 60 Funding of TB Control in Central Asia 62
4 The World Bank Role on TB Control 65
Part II: Country Profiles
5 The Republic of Kazakhstan 69 Main Challenges in Achieving Global TB Targets 70 Profile Introduction 72 TB Epidemiology 72 Tuberculosis Control 76 Financing TB Control 83
6 The Kyrgyz Republic 99 Main Challenges in Achieving Global TB Targets 100 Profile Introduction 101 TB Epidemiology 102
iii iv Contents
Tuberculosis Control 105 Financing TB Control 113
7 The Republic of Tajikistan 135 Main Challenges in Achieving Global TB Targets 136 Profile Introduction 138 TB Epidemiology 138 Tuberculosis Control 141 Financing TB Control 146
8 The Republic of Uzbekistan 159 Main Challenges in Achieving Global TB Targets 160 Profile Introduction 162 TB Epidemiology 162 Tuberculosis Control 166 Financing TB Control 175
References 193
LIST OF TABLES 1. Key Global TB Epidemiological and Financial Indicators 9 2. FSU and DOTS Approaches to TB Control 13 3. General Country Data 2002 18 4. Notification and Detection of TB in Central Asia 2002 23 5. TB Notification and Mortality Rate in Central Asia in 2003 23 6. HIV and TB/AIDS Cases in Central Asia 28 7. TB Notification and Mortality in Prisons in Central Asia 2003 30 8. MDRTB in Prisons in Central Asia in 2002 (%) 31 9. TB/HIV Cases in Prisons in Central Asia 2003 31 10. Infrastructure of TB Services in Central Asia 35 11. DOTS Strategy in Central Asia 37 12. DOTS Coverage in Central Asia 1998–2003 (%) 37 13. Estimated Percentage of all TB Cases Notified 39 14. TB Control in Prisons in 2002 43 15. TB Treatment Outcome 2002 46 16. DOTS Treatment Success 1995–1999 (%) 46 17. Public TB Spending by Country in 2002 47 18. Gaps in TB Spending by Country 2002 48 Contents v
19. TB Costs, Indirect Costs and Rates of Return 49 20. Donor Contributions for TB Control in Central Asia (thousands) 50 21. TB Notification and Mortality Rates per 100,000 in Kazakhstan 74 22. TB Notification and Mortality among the Prison Population 75 23. Percentage of Sputum Smear Positives among all TB Cases Notified 78 24. Treatment Outcomes for New Smear-Positive Cases Treated Under DOTS 83 25. Donor Assistance to TB Control in Kazakhstan (US$) 85 26. Donor Assistance to TB Control in Kazakhstan 86 27. Cost-Benefit Analysis 95 28. Direct, Indirect, and Total TB Costs in a Typical Year 96 29. Kazakhstan—SWOT Analysis 97 30. TB Notification and Mortality Rates per 100,000 103 31. TB Notification and Mortality Rates per 100,000 Prisoners 104 32. TB Institutional Structure 106 33. TB Beds and DOTS Coverage in Kyrgyz Prisons 109 34. Treatment Outcome in New Sputum Smear Positive Pulmonary TB Patients 112 35. Treatment Outcome in Re-Treatment Cases of Pulmonary TB Cases 112 36. Treatment Outcome of New Sputum Positive TB Patients in Prisons 113 37. Public Funding of TB Control Program in the Kyrgyz Republic 113 38. Donor Funding for TB Control Programs (US$) 117 39. TB Performance by Oblast and Inputs 131 40. Cost-Benefit Analysis 132 41. Direct, Indirect and Total TB Costs in a Typical Year 133 42. TB Notification and Mortality Rates in Tajikistan 138 43. TB Case Notification and Mortality among Prisoners 140 44. Percentage of Sputum Smear Positives among all TB Cases Notified 142 45. Treatment Outcome of New Smear Positive Cases in Dushanbe City (3 Cohorts) 145 46. Donor Funding for TB Control Programs (US$ thousands) 148 47. TB Performance by Oblast and Indicator 155 48. Cost-Benefit Analysis 156 49. Direct, Indirect and Total TB Costs in a Typical Year 157 50. TB Notification and Mortality Rates per 100,000 163 51. TB Notification and Mortality Rates per 100,000 by Oblast 164 52. TB in Prisons 166 53. New Pulmonary TB Cases 169 54. Inputs for TB Control in Prisons 1998–2002 170 vi Contents
55. Treatment Outcome in New Sputum Smear Positive TB Cases 174 56. Donor Assistance to TB Control (US$ thousands) 177 57. Donor Assistance to TB Control in Uzbekistan 178 58. Oblast Orientation by TB Budget Category, 2002–2004 182 59. Oblast Budget Profile and TB Outcomes 183 60. TB Performance by Oblast and Indicator 190 61. Cost-Benefit Analysis 191 62. Direct, Indirect and Total TB Costs in a Typical Year 192
LIST OF FIGURES 1. TB Notification Rates in Kazakhstan, Kyrgyz Republic, Tajikistan, and Uzbekistan xvi 2. HIV Infections Newly Diagnosed per Million Population 11 3. TB Notification Rates in Kazakhstan, Kyrgyz Republic, Tajikistan, and Uzbekistan 1990–2002 22 4. TB Mortality Rate in Central Asia per 100,000 Population 1990–2003 25 5. Estimated Number of Lives Saved by DOTS in Kazakhstan 1999–2001 27 6. Increase of TB/HIV Dual Infection among 20 years-old in Kazakhstan 29 7. Organizational Chart of the Kyrgyz National TB Program 33 8. TB Hospital Performance by Country 2002 45 9. TB Public Spending in Central Asia 2002 48 10. Donor Contributions by Country, 2002 51 11. Salaries and Drugs in National TB Programs 52 12. TB Costs as Percentage of GDP by Country 53 13. TB Performance Indicators by Country 54 14. TB Incidence Rates by Country or Region, 2002 55 15. Population Covered by DOTS 2002 55 16. Percentage TB Notification per Age Group in 2002 73 17. TB Notification and Mortality Rate per 100,000 73 18. Estimated Number of Lives Saved by DOTS in Kazakhstan 1999–2001 74 19. TB Beds per 100,000 Persons by Oblast in 2003 81 20. Turnover Rate and Bed Occupancy Rate in Kazak TB Hospitals in 2003 82 21. TB Public Spending in the Economy in 2002 84 22. Cost per TB Patient by Oblast in 2002 84 23. Distribution of TB Contributions by Donor 2002–2007 86 24. TB Budget Structure in 2002 87 25. Contribution for TB Control by Account in 2002 88 Contents vii
26. Distribution of TB Resources by Oblast in 2002 88 27. TB Spending per Capita by Oblast in 2002 in US$ 89 28. Participation of TB Budget Accounts by Oblast in 2002 90 29. TB Per Capita Spending and Cure Rates in 2003 91 30. TB Doctors and Cure Rates in 2003 91 31. TB Drug Spending and Cure Rates by Oblast in 2003 92 32. TB Beds and Cure Rates in 2003 93 33. TB Facilities and Cure Rates in 2003 93 34. TB Notification by Age and Gender in 2002 102 35. TB Notification and Mortality Rates per 100,000 103 36. Organizational Chart of the Kyrgyz National TB Program 107 37. Supply of TB Beds by Republican Institution, 2003 111 38. Republican TB Institutions Performance, 2003 111 39. Expected Public TB Spending, 2001–2008 (in Million Soms and US$) 114 40. Expected Public TB Expenditures per Capita, 2001–2008 (in Soms and US$) 115 41. Expected Public TB Spending as a Percentage of GDP and Health Care, 2001–2008 115 42. Participation of TB Budget in Government Expenditures, 2001–2008 116 43. Distribution of Donor Assistance 2002–2008 117 44. TB Expenditures per Capita by Oblast 2002–2003 (US$) 118 45. TB Cost per Patient by Oblast 2003 (US$) 119 46. TB Budget Structure by Category 2002–2003 119 47. TB Drug and Food Costs per Patient-Day by Oblast in 2003 ($US) 120 48. Drug and Food Participation in Oblast TB Budgets, 2001–2003 121 49. Share of Republican TB Hospitals in Total Expenditures 2001–2003 122 50. Structure of Republican TB Hospital Expenditures by Category, 2001–2003 123 51. Cost per Bed by TB Hospital 2003 123 52. Unitary Costs of TB Treatment-Related Components, 2003 124 53. TB Cases and Budget per Capita, 2002 125 54. TB Notification Rate and Budget per Capita, 2001–2002 126 55. Growth in TB Budget per Capita and Cure Rates 2001–2002 127 56. Growth in TB Budget per Capita and Case Fatality Rates, 2001–2002 128 57. Growth in TB Doctors per 100 Cases and the Cure Rate, 2001–2002 129 58. Spending on TB Drugs and Cure Rates, 2001–2002 130 59. Growth in TB Beds per 100 Cases and Cure Rates, 2001–2002 131 60. TB Notification and Mortality Rates 1998–2003 139 viii Contents
61. Age Specific TB Notification Rate by Gender, 2002 140 62. TB Epidemiological Situation in Prisons 141 63. TB Cases per Bed in Prisons, 1998–2002 143 64. TB Hospital Performance, 2003 145 65. TB Public Spending per Capita and as a Share of GDP, 2002–2003 147 66. Daily Costs of TB Inputs 2003 147 67. Structure of International Assistance by Donor 2002–2005 148 68. Composition of TB Budget by Program 2002–2003 149 69. Distribution of TB by Budget Category 2002–2003 150 70. Oblast Participation in the Public TB Budget 2002–2003 151 71. TB Spending per Capita by Oblast 2002–2003 152 72. TB Spending per Capita and Mortality Rates, 2003 153 73. TB Beds and Death Rates 154 74. TB Drugs and Death Rates 154 75. TB Notification Rate and Mortality Rate per 100,000 Population 163 76. Percentage TB Notification per Age Group in 2003 164 77. Newly-Registered HIV/AIDS Cases in Uzbekistan 165 78. TB Beds per 100,000 Population and per 1,000 New Cases, 1998–2003 172 79. TB Beds per 10,000 Habitants per Oblast, 2002 172 80. TB Hospital Performance in Uzbekistan 2002 173 81. Outcomes of DOTS in New SS (+) Cases in Karakalpakstan 1998–2002 174 82. TB Expenditures as a Percentage of GDP, 2002–2004 175 83. Cost per Day per TB Patient, New Case, and Bed, 2002 176 84. Projected Donor Participation in TB Control, 2002–2009 178 85. Distribution of TB Resources by Oblast, 2002–2004 179 86. TB Spending per Capita by Oblast, 2002–2004 180 87. Correlation between TB Patients and Budget Allocation, 2002 181 88. TB Budget Structure by Group of Institutions, 2002–2004 182 89. Distribution of Donor Contributions by Oblast, 2002–2004 184 90. TB Cases and Donor Contributions, 2002–2004 185 91. Importance of Donations in Oblast Budgets, 2002–2004 186 92. TB Public and Donor Allocations per Capita, 2003 (in Real US$) 186 93. TB Spending per Capita and Success Rates, 2002 187 94. TB Doctors and Success Rates, 2002 188 95. TB Facilities and Success Rates, 2002 189 96. TB Drugs and Success Rates, 2002 189 Contents ix
LIST OF BOXES 1. TB Study Objectives 3 2. TB and HIV/AIDS Study Objectives 4 3. TB Study Questions 5 4. DOTS Strategy 7 5. DOTS Results 7 6. Global Targets for TB Control 8 7. TB Study Main Findings 58 8. Key Actions to Control TB in Prisons 58 9. Key Actions to Control MDRTB 59 10. Key Actions to Control the Dual TB/HIV Infection 60 11. Key Actions to Improve DOTS Implementation 62 12. Key Actions to Improve Use of Resources 63 13. Bank-financed TB Control Projects in the Former Soviet Union 66
Acknowledgments
his study was prepared by a team led by Joana Godinho (Senior Health Specialist at Tthe Human Development Department of the World Bank), and including Jaap Veen (Coordinator of the European Unit of the KNCV Tuberculosis Association), Masoud Dara (TB Specialist of the KNCV Tuberculosis Association), James Cercone (Economist and President of SANIGEST), and José Pacheco (Economist at SANIGEST). Dorothee Eckertz, Andrei Mosneaga, and George Shakarishvili collected data for the study. Baktybek Zhumadil, Asel Sargaldakova,Jamshed Khasanov,and Dilnara Isamiddinova assisted with data collection and organized meetings with counterparts and other stakeholders in their respective countries: Kazakhstan, Kyrgyz Republic, Tajikistan, and Uzbekistan. Elina Manjieva, Natalia Turchina, Gizella Diaz, and Gabriel Francis assisted the preparation of the paper for publication. The authors are grateful to the staff of the Ministries of Health, Internal Affairs, Justice, and Finance; the TB Institutes and other public agencies, NGOs and international organ- izations assisting TB control in Central Asia for their inputs and collaboration in the preparation of this Study. Counterparts from the Ministries of Health and TB Institutes of Kazakhstan, Kyrgyz Republic, Tajikistan, and Uzbekistan reviewed the study before publication. Diana Weil, WHO Senior Policy Advisor, Holger Sawerth, Stop TB Medical Officer, Andrei Mosneaga, WHO Medical Officer in South Caucasus, and Enis Baris, Senior Pub- lic Health Specialist at the World Bank provided useful comments as well. The study team is thankful to Lilia Burunciuc, Country Program Coordinator, James Christopher Lovelace, Country Manager in the Kyrgyz Republic, and Armin Fidler, Sector Manager, for their comments and support, and to all other colleagues that have contributed with their helpful comments to the final report. The team thanks Stuart K. Tucker (at the World Bank’s Office of the Publisher) for preparing the study for printing.
The World Bank Vice President : Shigeo Katsu Country Director : Dennis de Tray Sector Director : Charles Griffin Sector Manager : Armin Fidler Task Team Leader : Joana Godinho
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Acronyms and Abbreviations
AIDS Acquired Immune Deficiency Syndrome AHP Ambulatory Health Posts AKF Aga Khan Foundation ALOS Average Length of Stay BOR Bed Occupancy Rate CAR Central Asia Republics CCM Country Coordination Mechanism CDC Centers for Disease Control and Prevention DALY Disability Adjusted Life Years DFID UK Department for International Development DOTS TB Directly Observed Treatment Short-Course DST Drug Susceptibility Testing ECA Europe and Central Asia ESCM Electronic Surveillance Case-Based Management System FDC Fixed Dose Drug Combination FGD Focus Group Discussion FGP Family Group Practices FMC Family Medicine Center FSU Former Soviet Union GDF Global Drug Fund GDP Growth Domestic Product GFATM Global Fund to Fight AIDS, TB and Malaria GLC Green Light Committee GMP Good Manufacturing Practice GNI Gross National Income GTZ German Technical Cooperation HBC High-Burden Countries HIV Human Immunodeficiency Virus HOPE NGO, Health Opportunities for People Everywhere HSR Health Sector Reform IDA International Development Association IDU Injecting Drug Users IEC Information, Education and Communication Campaign IFRC International Federation of Red Cross and Red Crescent Societies IUATLD International Union Against Tuberculosis and Lung Disease KAP Knowledge, Attitudes and Practices KfW German Development Bank (Kreditanstalt für Wiederaufbau) KNCV Royal Netherlands Tuberculosis Association MDGs Millennium Development Goals MDRTB Multi-Drug Resistant Tuberculosis MHIF Mandatory Health Insurance Fund
xiii xiv Acronyms and Abbreviations
MMR Mass Miniature Radiography (fluorography) MoF Ministry of Finance MoH Ministry of Health MoI Ministry of Interior MOIA Ministry of Internal Affaires MOJ Ministry of Justice MSF Médecins Sans Frontières N/A Not Available NDC National DOTS Centre (Uzbekistan) NGO Non-Governmental Organizations NIS Newly Independent States NRL National Reference Laboratory NTBC National Tuberculosis Centre NTBI National Tuberculosis Institute NTP National Tuberculosis Program OECD Organization for Cooperation and Economic Development PHC Primary Health Care PLWHA People Living with HIV/AIDS SES Sanitary Epidemiological Service SIZO Pre-Trial Detention Center SS+ Sputum Smear Positive SVAs Rural Doctors Ambulatory Health Posts SWAP Sector Wide Approach TB Tuberculosis TOR Terms of Reference ToT Training of Trainers UN United Nations UNDP United Nations Development Programme USAID United States Agency for International Development VCT Voluntary Counseling and Testing WFP World Food Programme WHO World Health Organization Executive Summary
uberculosis is still a significant health and economic problem in Central Asia, despite Tsome recent progress that may be due to improvements of the overall economic situation in these countries, and partial adoption of the DOTS Strategy recommended by WHO. Over 50,000 new cases have been detected in 2003, and over 7,000 people died due to TB in the four countries studied. This study has confirmed that it is highly unlikely that the Central Asian Republics succeed in achieving the global targets for tuberculosis control in the short-term, particularly in what concerns case detection. In the meantime, the epidemic continues to have a serious epidemiological impact and affects the economies of these countries, which incur productivity losses and direct costs that are estimated to range from 0.5 to 0.8 percent of GDP annually. The study of tuberculosis in Central Asia aimed at: