National Tuberculosis Control Program in Bangladesh : Progress Report Dr. Shamim Sultana Deputy Programme Manager, TB National TB Control Programme Directorate General of Health Services Mohakhali, Dhaka

BANGLADESH: Country Profile Situated in South Asia Population : 140.70 million (2006 projected estimate, based on 2001 Census) Area: 147,570 sq. km Density: 953 per km2 GNP per capita: 444 US$ Administratively, it has- Division: 6 District: 64 Sub District: 507

BANGLADESH: TB Situation 5th among 22 high TB burden countries ARTI: 2.14% 50% of adult population infected Estimated new cases of TB (all forms) per year : 227 / 100000 population Estimated new smear positive TB cases per year: 102/ 100000 population TB Prevalence (all cases): 406/100000 pop

BANGLADESH: TB Situation TB Mortality ( all cases per year) : 47/100000 population Percent estimated new adult cases of TB co-infected with HIV : 0.1% No representative DRS data available Estimated New TB cases MDR: 1.8% Estimated previously treated TB Cases MDR: 14%

BANGLADESH: TB Situation DOTS strategy- implemented in November 1993 DOTS Coverage: almost 99% TB Case Detection Rate 2006: 71.06% Treatment Success Rate ( 2005): 91.51% Source: WHO estimates of 2006

BANGLADESH: TB Situation TB Case Detection Rates: (2006) National : 71.06% Divisional : Dhaka 68.0% Chittagong 75.0% Rajshahi 61.4% Khulna 75.6% Barisal 90.9% Sylhet 81.8%

Smear +ve Cases: Treatment Success and Case Detection Rates (%); Since 1993

TB Situation from 2004 - 2006 General/All cases in 2004 Year 2004 2005 2006 Country Population: 137 million 140 million 140.7 million DOTS population coverage (%): 99% Number of TB cases notified (all cases): 90,741 122,907 145,164 % Detection*: 31% 32% 45.07% Number of pulmonary TB sputum-smear positive case: 62,228 88,576 101,988 46% 61% 71.06% Success rate of smear positive cases (%)[cure plus completion] : 89% 91.51% Please fill in table for 2002 and 2003. *Percentage of cases notified out of estimated cases

TB Situation of 2006 Reporting Unit Pulmonary Positive Upazilla 75.51 Pulmonary Negative % Extra Pulmonary New Total New Relapse Upazilla 75.51 2.23 14.07 8.19 82 Metro 47.87 6.58 27.54 18.01 13 CDC 42.97 4.23 35.24 17.57 5 70.26 2.90 16.89 9.95 100

Vision and Mission of NTP Tuberculosis is no more a public health problem in Bangladesh MISSION: National Tuberculosis Program (NTP) aims to strengthen the effort of TB Control through effective partnership, mobilizing resources and ensuring quality diagnostic and treatment services under defined Directly Observed Treatment Short Course (DOTS) strategy. The service should be equally available to all people of Bangladesh irrespective of age, sex, religion, ethnicity, social status and race.

Vision and Mission of NTP (Cont.) GOALS OF NATIONAL TB CONTROL PROGRAM The overall goal of TB control is to reduce morbidity, mortality and transmission of TB until it is no longer a public health problem

Vision and Mission (Cont.) OBJECTIVES OF NATIONAL TB CONTROL PROGRAM - Reach and thereafter sustain the 2005 targets- achieving at least 70% case detection and 85% treatment success among TB cases under DOTS In order to then, - Reach the interim target of halving TB death and prevalence achieving the Millennium Development Goals set by 2015

Areas of GO-NGO Collaboration in TB Control in Bangladesh Area of Collaboration Government NGOs/ Partners Implementation Policy, Planning and Budgeting National guidelines Overall coordination Infrastructure Specific areas as per MoU Case finding and Case Holding Equipment/supplies Diagnosis, Treatment, DOT , Follow-up, Management of complicated cases Referral centres Suspect identification, Referral for Diagnosis, Diagnosis and Treatment, DOT and Follow-up Training Training of Trainers (TOT) Responsible for pertaining all forms of training/ orientation to all categories of GoB and NGOs/ Partners Local training only for respective NGO staff as per NTP curricula, support government training

Areas of GO-NGO Collaboration in TB Control in Bangladesh (Contd.) Area of Collaboration Government NGOs/ Partners Drugs and Logistics Management Central procurement Distribution Local storage Local storage and distribution Supply indent Monitoring ,Supervision and Evaluation Recording and Reporting Overall Monitoring and Supervision External and Internal Evaluation Local Monitoring and Supervision Participate in internal and external evaluation Advocacy, Communication and Social Mobilization (ACSM) Policy, Planning and Budgeting Advocacy meetings with all stakeholders National campaigns Outreach activities at local community

ROLE OF THE NTP AND ITS IMPLEMENTING PARTNERS AT DIFFERENT LEVELS Partners/Implementing agencies NTP Central Level Responsible Persons: Director- MBDC & Line Director-TB/Leprosy, Deputy Director-MBDC , Asst. Director, Program Manager-TB, DPM-TB and MOs Responsibilities: Policy formulation, Planning, Budgeting, Coordination with partners,Operational Guidelines, HRD, ACSM, EQA, Procurement and Supply of Drug and Logistics, MIS, Supervision, Monitoring & Evaluation and Operational Research Responsible Bodies: Academic Institutes, NGOs and Professional Associations Responsibilities: Civil society and private sector involvement,ACSM,Recording and Reporting, Supervision and Monitoring, Implementation of Operational Research

ROLE OF THE NTP AND ITS IMPLEMENTING PARTNERS AT DIFFERENT LEVELS (Contd.) Partners/Implementing agencies NTP Responsible Persons: Divisional Director Health and Deputy Director, Health. Responsibilities: Supervision and Monitoring according to NTP guidelines, coordination with NTP and partners Divisional level Responsible Bodies: City Corporations, NGOs, Chest Hospitals, Academic Institutes, Corporate Health Services, Private Sectors and Prisons. Responsibilities: Implementing DOTS, Management of referred cases,ACSM, Recording and Reporting , Supervision and Monitoring Responsible Persons: Civil Surgeon Consultant-Chest Disease Clinic, MO and PO- TB-LEP Responsibilities: Supervision, Monitoring and Evaluation, EQA,Training, technical guidance, coordination with NTP partners and implementing DOTS District Level Responsible Bodies: Academic Institutions, District Hospitals, Chest Disease Clinics, NGOs. Responsibilities: DOTS Implementation, Management of referred cases, Supervision, Monitoring, Quality Assurance, networking with private providers, ACSM,Recording and Reporting, indenting for drugs and logistics.

ROLE OF THE NTP AND ITS IMPLEMENTING PARTNERS AT DIFFERENT LEVELS (CONT.) Partners/Implementing agencies NTP Responsible Persons:UH&FPO, MO LTCA Responsibilities: Implementation of DOTS, Supervision, Monitoring and Evaluation, Training, Recording and Reporting, Coordination with NTP partners Responsible Bodies: UHC, NGO partners Responsibilities: Identification of suspects, sputum collection and examination, Training, ACSM, DOT,Follow Up, Supervision, Recording and Reporting, and Indenting drugs and logistics Upazila Level

ROLE OF THE NTP AND ITS IMPLEMENTING PARTNERS AT DIFFERENT LEVELS (Contd.) Partners/Implementing agencies NTP Responsible Persons: HI,AHI, HA, MA Responsibilities: ACSM, Suspect identification and referral, DOT, Follow Up Responsible Bodies: Health sub-centers, NGO partners. Responsibilities:ACSM, Suspect identification and referral, DOT, Follow Up,Sputum collection and transportation to laboratory Union/ward Level Village Level Responsible Persons: Community Health Workers (Shastho Shebikas), Village Doctors, Cured patients Responsibilities: Suspect identification and referral, DOT, Follow Up

National / International Partnerships (list of institution) Type of Partnership 1. NGOs (BRAC, LTCC UPHCP, NSDP) DOTS Service Delivery 2.NATAB Civil Society Involvement in TB Control 3. ICDDR,B Operations Research 4. Private Practitioners DOTS Service Delivery and Collaborate With NTP NGO Partners 5. Academic Institutes, Public and Private Hospitals DOTS Service Delivery, Referral Centres Please identify all country partnerships, including financial/donor, technical, NGO, local agency, medical society, etc.

National / International Partnerships( Cont.) (list of institution) Type of Partnership 6. Corporate Sectors, Work Places DOTS Service Delivery 7. Special Population ( Prison, Defences) 8. WHO Technical Assistance 9. GFATM, CIDA, USAID, JICA,WB Financial Assistance 10. RIT,KNCV,URC, IUATLD

Resource Mobilization :GFATM Grants (US$ in million) Principal Recipient Government NGO-BRAC Total Round 3 (Period: 2004-2009) 15.45 27.02 42.47 Round 5 (Period: 2006-2011) 26.45 19.52 45.97 41.9 46.54 88.44 Through this well established partnership Bangladesh was able to mobilize a significant amount of grant in 2004 and 2006 from the Global Fund to fight AIDS, TB and Malaria (GFATM) which gave momentum to the TB Control programme.

Current and Planned Activities Increase case detection and maintain high cure rates through strengthening DOTS services including quality of lab services Involve all health care providers Create demand for services through comprehensive advocacy, communication and social mobilization Strengthen the procurement and supply system Strengthen supervision, monitoring and evaluation Management of Multi Drug Resistant TB TB/HIV collaborative activities

NTP Achievements Expansion of DOTS in Metropolitan Cities Introduction of DOTS in prisons, academic institutions and workplaces Sustaining strong collaboration between Government and Non-Government organizations Access to the Global DOTS Expansion plan funded by CIDA, Global Drug Facility (GDF), Global Fund to Fight AIDS, TB and Malaria (GFATM) and strong technical support from WHO Please describe the 3 major achievements accomplished in 2003 toward reaching the 2005 global TB targets. Examples: DOTS has been expanded to 20 districts "x" number of hospitals started DOTS implementation Funding for TB control covers all needs expressed in the national plan

NTP Achievements(Cont.) 5. Detection of estimated new smear positive cases under NTP increased to over 70% in 2006 as compared to 34% in 2002 and treatment success rate to over 91% (2005) 6. Establishment of External Quality Assurance of smear microscopy 7. Initiation of Prevalence Survey Please describe the 3 major achievements accomplished in 2003 toward reaching the 2005 global TB targets. Examples: DOTS has been expanded to 20 districts "x" number of hospitals started DOTS implementation Funding for TB control covers all needs expressed in the national plan

NTP Achievements (Cont.) 8. Awareness campaigns initiated through mass media 9. Steps taken to function DRS and implementation of DOTS-Plus Project 10.Steps taken to implement PPM-DOTS, TB-HIV

Major Challenges Health Sector Reform Effective partnership to cover hard to reach/special areas: Private Hospitals and Clinics, Expansion in Defense Hospitals, Prisons, Brothels, Slums and Industrial Units, homeless population in difficult terrains Human Resource Capacity Development MDR-TB and HIV-TB Co infection Quality assurance of lab services Uninterrupted supply of drugs Strengthening of supervision and monitoring Dependence on external funding

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