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Multi-Drug Resistant TB: A Policy Framework on Decentralised and Deinstitutionalised Management for South Africa

Multi-Drug Resistant TB: A Policy Framework on Decentralised and Deinstitutionalised Management for South Africa
Publication date: 
May 2019


This Policy Framework provides guidance to treat MDR-TB patients closer to their homes. It describes the need for and benefits for decentralisation and deinstitutionalisation of multidrug-resistant tuberculosis (MDR-TB) care and treatment. It also describes the necessary organisational structures and human resources requirements and expected functions of each level of operations. The monitoring and evaluation focus on the level and content of recording, reporting and monitoring indicators.

The South African National Department of Health (NDoH) has implemented a DR-TB management programme since early 2000. Previous DR-TB treatment guidelines dictated that all DR-TB patients be hospitalised for at least six months. In 2011, The National TB Programme introduced a policy framework on decentralised and deinstitutionalised management of MDR-TB in South Africa. This policy was revised in 2018, following a successful implementation of decentralised MDR-TB care.

Decentralised management of DR-TB refers to the transfer of responsibility for treating MDR-TB patients to lower levels of the system on condition that they meet specific criteria. It includes the management of DR-TB in decentralised DR-TB units, satellite multi-drug resistant TB (MDR-TB) units, or in the community using mobile teams and community caregivers and households. WHO’s MDR-TB guidelines define community-based care and support as any action or help provided by, with or from the community, including situations in which patients are receiving ambulatory treatment.

The revised policy provides the modalities of DR-TB care. The main modalities are admission, ambulatory care or home-based/ community care. All these are applicable. The use of a modality of care is dictated by the patients’ condition. The general condition of the patients dictates whether he or she should be admitted or not, not the smear positivity. Very sick patients (RR/MDR-TB and XDR-TB) require admission while those who are not very sick will be treated in ambulatory. Average duration for admission should vary from 2 weeks to 2 months depending on the patient’s condition. In some rare circumstances, it may be important to keep an individual patient in the hospital until a negative culture is obtained – but this should be the exception rather than the norm. Recent evidence suggests that a significant proportion of DR-TB is due to ongoing transmission of already resistant strains.

We have also noted that XDR-TB patients now have better treatments outcomes than RR/MDR-TB patients.

Before the introduction of the policy framework on decentralised and deinstitutionalised management of MDR-TB there were only 17 DR-TB treatment initiation sites. To date there are 658 sites in 89 % of sub-districts. Treatment success rate has improved from 40 % to 55 % during the same period. We are aiming at establishing and maintaining at least one MDR-TB treatment initiation site per sub-district. The treatment initiation site may be managed by a medical officer, a clinical associate or a clinical nurse practitioner. Each treatment initiation site must have at least access to the following minimum requirements: quality assured medicines, quality assured laboratory services and Electrocardiogram devices (ECGs) as well as a data recording and reporting system in place.

The following health facilities framework for management of DR-TB patients was proposed in the previous policy document:

  • Centralised DR-TB unit also known as “Provincial Centre of Excellence”;
  • Decentralised DR-TB units;
  • Satellite MDR-TB units; and
  • Community Support through primary health care services to assist with​ Deinstitutionalisation of patients, including:
  1. Mobile teams, and
  2. Community caregivers.

In this revised policy framework, an emphasis is placed on the importance of the functions of MDR-TB treatment initiation sites. We would like to focus on the patient’s initiation aspect due to only some sites having the capacity to initiate and monitor MDR-TB patients while all health care facilities in the country are able to monitor MDR-TB patients. Monitoring patients means adhering to the instructions of the treating health care professional, sourcing medicines and providing them on monthly basis or when necessary, conducting laboratory tests, performing ECGs and report to the treatment initiating facility.

This Policy Framework stipulates that all RR/MDR-TB patients in fair to good general condition may be started on ambulatory treatment regardless of their bacteriological status. Such patients are expected to be without extensive disease and stable. RR/MDR-TB that are admitted for treatment initiation may be kept until two negative smear microscopy results are received if they were positive initially or when their general condition improves.

Furthermore, while this document is generally referring to the decentralisation of care for RR/MDR-TB; some key principles in this document are applicable to XDR-TB as well.