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FEATURE STORY

China: Tuberculosis Control Project

September 24, 2010

Overview
The China Tuberculosis Control Project was the largest tuberculosis (TB) control project funded by the World Bank in the world. The project objective was fully achieved and targets for case detection and cure rates for TB were exceeded. The project registered and treated close to 1.6 million new patients. More than 1.5 million of these patients completed treatment (94.2 percent) and nearly 1.5 million patients were cured (93.8 percent).

Challenge
By 2002, China had one of the highest “TB burdens” in the world—after India—and was facing particular challenges in Multi-Drug Resistant TB (MDR-TB) and HIV/TB co-infection. More than 600,000 people were estimated to be infected with HIV, about one-third of them expected to die from TB. Parts of China had some of the highest rates of MDR-TB in the world. The disease also contributes to the cycle of poverty for many Chinese citizens. The largest group in the population affected by TB is adults in their most productive years. Their sickness and death contribute to the impoverishment of entire families.

A key challenge in addressing this problem was to increase the financing for and improve the quality of healthcare in the poorer provinces. Indeed, in the 1980s, health financing in China shifted from a centralized to a decentralized and individual responsibility approach. The share of government spending on health decreased substantially and “out-of-pocket” spending increased. The extremely low coverage of health insurance was especially problematic for TB control. One survey showed that 37 percent of TB patients were unable to seek care because of financial difficulties, and many TB patients became poor because of treatment costs.

Despite the major public health threat posed by TB, funding for its control remained insufficient. The less-developed provinces in western regions found it particularly hard to find the financing for TB control.

Approach
The Tuberculosis Control Project covered 16 provinces, selected for their low per capita incomes, high prevalence of TB and commitment to implement the program with local financial participation. While it covered the entire population of these provinces (over 680 million people), it focused on the poor. Special arrangements were made to maximize project benefits for the high proportion of ethnic minorities and other socially vulnerable groups in the project provinces.

The project piloted and scaled-up the World Health Organization (WHO)-recommended “DOTS” (Directly Observed Treatment, Short-course) strategy, which involves not just finding and curing infectious TB patients, but ensuring that they receive free care and that they take their full six-month treatment.

The project also emphasized institutional development, policy and program development, and coordination at the national level. The bulk of activities focused on the improvement of access to and the quality of TB control services. The project, which incorporated lessons from two previous TB-control projects, was an integral part of the National TB Control Program (NTP). TB control efforts were tailored to the local context, patient profile and existing health service delivery systems. Performance-based incentives were used, with doctors and health workers in rural and urban areas receiving a fee for reporting and referring a TB patient and for supervising a patient to complete treatment for the entire six months.

Results

  • From 2002 to early 2009, the project registered and treated approximately 1.598 million new smear-positive patients;
  • 1.505 million patients completed the treatment (94.2 percent) and 1.499 million patients were cured (93.8 percent).
  • The project reduced TB-associated deaths by 770,000, and prevented 20 million people from being infected by TB and 2 million people from falling ill.
  • The project achieved its target of a 70 percent case detection rate of new smear-positive cases; the rate exceeded 70 percent in 2005 and has remained at around 77 percent since.
  • The cure rate for new smear-positive cases greatly exceeded the goal of 85 percent.
  • A Ministry of Health evaluation of the project noted that the focus on western and poorer regions of China was critical to bolstering the national TB strategy.
  • The project created a supportive policy environment and invested in institutional strengthening to improve case finding and treatment effectiveness.
  • Health education activities were conducted to improve knowledge and awareness of TB under the national IEC plan using a health promotion resource database developed with the project’s support. The project tailored health promotion materials to its target population by using the languages of main ethnic minority groups.
  • The project achieved its objective of establishing adequate institutions at all government levels to control TB and established effective TB control institutions by strengthening their capacity in financial management and planning and improving the quality of TB care.

Bank Contribution
The project—integrated from its inception into China’s overall national TB control program—was financed through a US$101.44 million loan from the World Bank; a US$35.65 million grant from the U.K. Department for International Development (DFID); a US$14 million grant from Japan; and US$124 million in government counterpart funding. Other major international partners included the Bill & Melinda Gates Foundation, the WHO, KNCV Tuberculosis Foundation (Netherlands), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

Partners
Project preparation benefited from outstanding collaboration and partnership between the Ministry of Health, the World Bank, the WHO and DFID, each organization playing the role that corresponded to its comparative advantage. The WHO provided technical leadership and guidance; the World Bank focused on implementation arrangements, fiduciary aspects, and project financing mechanisms. The KNCV Tuberculosis Foundation aided the Bank on technical matters. DFID provided valuable inputs financially and technically, particularly in relation to the pro-poor orientation of the project.

Moving Forward
The project successfully achieved its objectives, but TB control remains a major long-term public health challenge for China. Many issues remain, which could not be accommodated under the scope of the completed project. During the past 10 years, China has implemented significant health sector reforms particularly in the area of health financing. It is important that TB control and other public health programs are “mainstreamed” in these systemic reforms rather than being isolated public health interventions.

The next phase of TB control and of potential collaboration between China and the Bank includes reducing the inequity in TB detection and treatment, the programmatic management of MDR-TB, the introduction and scale-up of new diagnostic tools and drugs, TB control and health system reforms, and the strengthening of the role of hospitals and laboratories in TB control.

Since the Bank and China started collaboration on TB control, the global donor architecture in relation to TB care has significantly changed, mainly as a result of the arrival of the Global Fund and a number of philanthropic organizations. It is important to continue coordinated efforts among the Ministry of Health and various donors to maximize synergy and to reduce duplication.