550 million Chinese people are infected with tuberculosis (TB). About ten percent of them may go on to develop TB disease, which kills 130,000 people annually. In 1991 the National TB Control Programme launched a ten year strategy to tackle this huge problem. How effective has it been and what are the challenges for the future?

Research by the Liverpool School of Tropical Medicine used published and unpublished data and personal communications with TB professionals in China to address this and other questions.

Although effective measures can stop infected people from developing active disease, these are not practical for such a huge number of people. So treating infectious TB patients is seen as the most effective way to control TB in China. The TB programme, which includes implementation of the World Health Organisation's DOTS strategy, increased the cure rate to more than 90 percent for registered TB patients. It also upgraded the skills of health professionals, developed infrastructure, improved the quality of TB services, increased awareness of TB among the public and political leaders, and strengthened commitments by central and local governments.

However, several problems remain:

• Only 30 percent of active cases are detected, leaving many suffering from the disease and able to infect others.
• Substantial proportions of TB patients do not receive or complete standardised treatment.
• An increasing proportion of patients have multi-drug resistant (MDR) TB – 7.6 percent among new patients (compared with a global average of 3.2 percent) and as high as 17.1 percent among TB relapse cases.
• TB control is difficult for rural migrants who work and live in poor conditions in urban areas, who often lack medical insurance and moving frequently.

The researchers identified the possible causes of these problems as:

• socioeconomic barriers to care seeking, including financial difficulties, social stigma and low awareness of TB as a serious disease
• ineffectiveness of TB services, particularly in poor areas where inadequately qualified health workers lack necessary medical equipment
• lack of cooperation between health facilities, often due to financial constraints
• weak political and financial commitment from local governments.

With substantial support from international organisations and central government, China has an excellent opportunity to build on its successes in TB control. The expansion of DOTS to the whole country should be a top priority. The researchers recommend that those involved in the TB control programme should:

• develop rational mechanisms to finance all the health facilities responsible for TB control and prevention and provide appropriate incentives for health staff
• mobilise support from local governments, particularly in poor areas
• develop proactive approaches to TB case finding, possibly through a community-based surveillance system using trained village health workers
• develop information, education and communication (IEC) campaigns to increase awareness of the TB epidemic, publicise free services and reduce stigma
• provide financial support to the poorest patients to cover indirect costs associated with TB treatment
• use incentives and disciplinary action, if necessary, to improve cooperation between health facilities.

Source(s):
‘What lessons can be drawn from tuberculosis (TB) control in China in the 1990s? An analysis from a health system perspective’, Health Policy 72: 93-104, by S. Tang and S.B. Squire, 2005
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 27 January 2006

Further Information:
Shenglan Tang
International Health Research Group
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool
L3 5QA
UK

Tel: +44 (0) 151 7053197
Fax: +44 (0) 151 7053364
Contact the contributor: S.Tang@liverpool.ac.uk

Liverpool School of Tropical Medicine (LSTM), UK

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