Turkey TB Programme Review

1. Turkey TB Programme Review 26 March to 6 April 2006

2. Review mission 7 teams 10 international and 15 national team members Provinces visited Ankara IstanbulBursa Duzce Erzurum Trabzon Rize Diyarbakir Mardin

4. Places visited

5. Constraints and challenges • DOTS expansion has been slow • Central political commitment not always translated into effective functioning TB programme at provincial and district levels (some provinces lack TB coordinators) • The Central TB unit has limited stewardship capacity • Regular supervision is not performed and there is not available budget to support it • No available specific data on HR for TB control, distribution and skill mix is inadequate in some provinces • Discontent with the revolving fund (bonus system) which is unfair with TB control staff

6. Constraints and challenges • Health system transformation and integration with PHC offer opportunities to TB control but integration without adequate stewardship and training capacity will be detrimental • Sputum microscopy is not routinely used for diagnosis and treatment monitoring • The Ankara Central Hifzıssihha Reference Laboratory is not officially designated by the MoH as the National Reference Laboratory • Several laboratories perform sputum microscopy, culture and DST without adequate bio-safety and QA programme

8. Constraints and challenges • Too many patients are unnecessarily hospitalized during initiation of treatment • No adequate referral system between TB dispensaries and hospitals, and poor or not existent integration with primary care • Management of TB in children is not standardized • Fixed dose combinations are not available • All anti-TB drugs can be obtained without prescription • No standardized approach and guidelines on contact tracing and some practices are not justified

9. Constraints and challenges • Numerous groups are screened unnecessarily • Recording and reporting forms were introduced without adequate training and are erratically used • There is no systematic reporting from hospitals and no system for laboratory reporting of confirmed cases • No nationwide data on MDR-TB • No guidelines for management of MDR-TB and self administration of treatment during continuation phase

10. Constraints and challenges • Poor collaboration between TB and HIV/AIDS programmes • PPM not properly address, no coordination, guidelines or defined TOR • Lack of understanding on advocacy and the role of empowered communities on TB control • Basic operational research is not commonly done • No TB coordinator at the Istanbul Provincial Health directorate • Insufficient HR capacity at TB dispensaries and laboratories • Planned rapid scale up of DOTS without proper planning

11. Recommendations Political commitment and DOTS Expansion • Sustain and enhance Political commitment to TB control • Expand the TB Scientific Committee to include representation of all stakeholders • Elaborate a 5 year strategic plan for DOTS expansion and endorse it by the MoH. The Annual DOTS implementation plan should be updated yearly • Review and update Guidelines for all aspects of TB diagnosis, treatment and control • Elaborate and implement system for routine programme monitoring, supervision and evaluation • Include dedicated funds for training, monitoring, supervision and programme evaluation in the MoH budget for TB control

12. Recommendations Human Resources • Assess existing human resources, including laboratory, to ensure adequate number of trained staff are available at all levels. • Elaborate a HR development plan according to the identified needs • Re-define roles and responsibilities, include in job descriptions and ensure appropriate training • Appoint training coordinators at central and provincial levels to assess training needs, develop materials and ensure regular, coordinated and standardized training • Define the role of primary health care staff in TB control and provide training and empowerment • Revise the Revolving Fund to appropriately reward health workers in all levels of TB care and control

13. Recommendations Health System Transformation • Ensure NTP technical and stewardship capacity to provide necessary knowledge and skills to PHC. Regular training, supervision, M/E are important. • Re-evaluate and re-organize the functional structure of the NTP. Review the skill-mix at the Central Unit in order to provide oversight and stewardship to the provinces and play the leading role in TB Control • Establish the position of provincial TB coordinator and ensure official recognition • Maintain TB dispensaries, re-define their role in view of the planned integration with PHC and empower them to coordinate TB control locally • Mobile TB Control Groups should be preserved and re-evaluate their organization, roles and responsibilities in PHC integration

14. Recommendations Diagnosis • Recommend and implement nationwide use of smear microscopy for diagnosis and treatment monitoring • Establish a laboratory network and ensure regular QA through QA programme. Implement bio-safety in all laboratories. • Officially designate the reference laboratory in Ankara as the National Reference Laboratory with clear TOR. • Rationalize the number of laboratories performing microscopy, culture and DST according to local needs and workload.

16. Recommendations Treatment • Treatment in hospitals should always be administered under D.O. Organize D.O.T. in TB dispensaries in collaboration with PHC and other providers. • Number of hospitalized TB patients should decrease with PHC integration and follow indications for hospitalization. • Paediatric TB cases should be treated according to existing guidelines and reported to the NTP. BCG vaccination at birth should be maintained and performed by PHC.

17. Recommendations Drug supply • Maintain the system for centralized drug procurement. All TB drugs, including second line drugs, should be provided free of charge to all patients. • Ideally, TB drugs should only be available through the TB programme. • Fixed Dose Combinations (FDC) of demonstrated bioavailability should be used, especially in the absence of direct observation of treatment.

19. Recommendations Contact tracing and screening • Guidelines for contact tracing and preventive chemotherapy should be updated. • The TB screening programme should be re-defined in order to target actual risk groups for TB.

20. Recommendations Recording and reporting • It is not recommended to drastically change recording and reporting forms in near future • Training should be done on their proper use. • Simplify them as possible. • Each reporting unit (including all hospitals) should appoint a person responsible for TB registration and reporting. • Hospitals should be encouraged to use at least the TB patient register. • TB dispensaries should include all patients from prisons in the TB patient register. • Electronic individual case reporting should be implemented.

21. Recommendations Drug resistance and MDR-TB • A nation-wide drug resistance survey should be planned and performed. • National guidelines for management of MDR-TB should be developed, endorsed, disseminated and implemented.

22. Recommendations TB/HIV • A collaborative framework for TB and HIV/AIDS programmes should be developed. Public-Private DOTS • An agreed policy defining roles of all stakeholders in TB control should be developed.

23. Recommendations Istanbul • Istanbul's unique TB situation should be specifically addressed in the National Strategic Plan. • Establish a TB Advisory Committee consisting of all stakeholders to advise and assist the Provincial Health Directorate in developing a plan for DOTS expansion • Implementation of the Istanbul DOTS Expansion Plan should be monitored periodically by the MOH.

25. Update Improvement of TB Surveillance – training done in TB Surveillance in March 2007 with WHO EURO financial and technical support Strengthening the laboratory network- mission of head of SNL Daniela Cirrillo later in May 2007 in Turkey Support offered to NTP staff member of participating in TB/HIV training in Sondalo, summer 2006 The report is in for editing and then will be placed on the WHO EURO web page

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