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Summary Report on Decentralised and Deinstitutionalised Management of Multi-Drug Resistant Tuberculosis Services in South Africa

Publication date: 
Oct 2017

Drug resistance is a major challenge in the control of Tuberculosis (TB), which itself remains a global public health concern. The incidence of Multi-drug Resistant (MDR) and Extensively Drug-resistant (XDR) TB is increasing, with an incidence rate of 70 per 100,000 people amidst a TB-HIV co-infection proportion estimated to be 60 to 80% in South Africa. In 2016 the World Health Organization (WHO) reported that South Africa has the 6th highest incidence of TB cases and the 5th highest number of Drug-Resistant TB cases in the world.

In 2009, the confirmation of M(X)DR-TB involved patients being admitted at DR-TB sites and only discharged once the patient has culture converted. With only 17 DR-TB units and an estimated 2,000 beds available throughout 53 health districts, this resulted in nearly half of the diagnosed cases not initiated on treatment and patients having to wait for up to three months for admission. Delayed management posed a threat to the control of MDR-TB due to increased risk of transmission from patients not admitted for treatment.

To respond to the challenge, and to manage the threat the dual epidemic of HIV and TB posed to the country, in August 2011 the National Department of Health (NDoH) launched the policy framework on decentralised and deinstitutionalised management of MDR-TB, which transfers the responsibility of treating MDR-TB patients from a hospital-based MDR-TB referral system to community-based treatment centres.

The need to decentralize MDR-TB services came with the astonishing patient load and availability of beds in the DR-TB treatment initiation sites. During 2010, a total of 5,313 MDR-TB and 613 XDR-TB patients were initiated on treatment.

There were only 2,532 beds available countrywide, yet the need was for 3,274 beds. This resulted in a shortfall of 742 beds as MDR-TB patients were each expected to be admitted for six months and XDR-TB patients were each required to be admitted for 12 months.
In 2011 the MDR-TB decentralisation and deinstitutionalisation policy framework was implemented in all nine provinces in South Africa, which has led to the expansion of MDR-TB treatment access and care to rural areas with restricted access to DR-TB services and care. The roll-out of the decentralisation initiative followed a systematic approach, where each province had to develop and implement a provincial decentralisation plan, revised on an annual basis. This required the assessment of facility readiness, training of health care professionals, and ensuring access to laboratory services, uninterrupted DR-TB Drugs supply, audiology services, and availability of Electrocardiography (ECG) machines on site.

The initial target was to establish at least one treatment initiation site per district. This was achieved in 2015. The current target is to achieve at least one MDR-TB treatment initiation site per sub-district. So far, 237 sub-districts have at least one MDR-TB treatment initiation site, while 40 sub-districts do not have an MDR-TB treatment initiation site, which translates into 86% sub-district coverage. Currently, there are 651 treatment initiation sites across all provinces in 237 sub-districts.

Furthermore, the decentralisation of MDR-TB services has resulted in Nurse-Initiated MDR-TB treatment (NIMDR), hencethere are a number of sites where clinical nurse practitioners and clinical associates initiate MDR-TB treatment. There are 306 injection teams across the country that are providing injections at patient’s homes, supervising the intake of oral tablets, and also educating their families about infection prevention and control.

In 2011 the programme also established an ototoxicity prevention programme for all patients receiving second-line injectables for routine audiological monitoring and intervention. To date, 126 portable automated audiometers have been distributed to sites in order to support ototoxicity screening and monitoring.

The MDR-TB decentralisation programme has been a remarkable success and has resulted in a progressive increase in access to DR-TB services in South Africa, which has strengthened the referral pathways for improved patient linkages and retention to DR-TB care, treatment and support services. The treatment success rate for MDR-TB has increased from below 40% (2010 cohort) to 54% (2014 cohort).