Spotlight on Tuberculosis control in Thailand

Based on an exclusive interview Citizen News Service - CNS did with Dr Sirinapha Jittimanee, Public Health Officer, Tuberculosis Bureau, Department of Disease Control, Ministry of Public Health, Thailand

Thailand is one of the 22 TB high burden countries in the world. According to the WHO Global Tuberculosis Report 2012, Thailand, with a population of 70 million, had about 86,000 TB incident cases and 110,000 TB prevalent cases in past year. Case detection rate for all forms of TB was 76% and treatment success rate was 85% (in 2010).

THAI TB PROGRAMME
In Thailand, the TB Bureau is responsible for the multi-tiered National TB Programme. There are 12 regional offices at the sub-country level, with each regional office covering 4-5 provinces. Thus there are as many provincial health offices under each regional office and under each the provincial health office there are several community hospitals. Each Provincial health office is responsible for its own district—doing supervision, collecting reports, provide trainings, conduct meetings, etc. At the rural or community level, there are government healthcare facilities well-equipped for sputum microscopy and HIV testing, but for culture tests and drug susceptible tests (DST) the sputum needs to be sent to the laboratories at the provincial level.

UNIVERSAL HEALTH INSURANCE - SMART INVESTMENT!
Access to TB treatment is not a problem because the country boasts of a universal health insurance scheme which is free for all its citizens. Under this scheme the Thai Government pays THB 2000 per year to a hospital (for every catchment area) to cover 20,000 population and meet the entire healthcare needs of those 20,000 people. The hospitals are able to manage reasonably well within this budget, as by and large not everyone of 20,000 people fall ill. People covered through this insurance do not have to pay at all. This health insurance scheme helps the Thai TB programme a lot too. Cost benefit analyses have been done that show that this health insurance scheme results in considerable financial savings for the government - patients come earlier to the hospital, get diagnosed early, get care early, are not very sick and can go back to work early. Even the World Bank is interested to find out if Thailand’s health system model can be replicated in other countries said Dr Sirinapha Jittimanee to Citizen News Service - CNS.

PUBLIC HEALTH SYSTEM
Although there is a private health sector, there is not much cooperation between the private and public health sector. Very few people (those who are covered by other non-government health insurance schemes) seek private healthcare, and almost 99% of the TB patients seek TB treatment in government or public hospitals. Most of the TB patients are poor and so cannot afford private clinics. Moreover they are able to access good quality TB care in government hospitals for free.

DAILY DOSE ANTI-TB REGIMEN
Thailand’s National TB programme follows the daily dose regimen (and not intermittent therapy that is given in India) and the patients take the TB medication on their own. Usually there is some health centre (under a district hospital) that is close to the patient’s home, which the patient visits once a month to collect the drug supply for the entire month. Thereafter a healthcare worker visits patients every week to see if they are taking drugs on time and attend to other issues if any. Dr Srinapha informs that, even though Thailand doesn’t really do DOTS and patients take their own medicines, still our treatment success rate is good and relapse rate is very low (as compared to other countries that do DOTS). For MDR-TB treatment however, we follow DOTS and patients have to go to the health centre every day for their oral medication and injections.

CHALLENGES
Dr Srinapha concedes that, despite a good public health system and high detection rates, Thailand does face a lot many challenges in the field of TB control. She informs that, “We have a number of community groups, such as non-Thai migrants, that are not insured by the universal health insurance of Thai government. Also people who are mobile and/ or do not have a house registration number; or those without a birth certificate and/or national identity (ID) number are not eligible for this insurance and thus are not able to access free healthcare services. It becomes very difficult for them to get diagnosed if they have TB because they have to pay for chest X-ray or sputum microscopy and other related services which might be beyond their means. But once they are diagnosed with TB, then they too can get free TB drugs. But non-Thai migrants are often unwilling or hesitant to come to receive treatment from a government facility even if they are diagnosed for TB. So the hardest part for non-Thai migrants, even though the Government pays for their treatment, is to get diagnosed. Right now we have financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) which will end in next two years. That is a challenge to sustain resources.”

SMEAR-NEGATIVE TB NOT A GOOD SIGN
“Two weeks ago we had found that proportion of smear negative to smear positive is very high and that Thailand has an increasing death rate. This is a sign of something wrong in the community. The patients do not have any barrier to accessing care but when they are smear-negative they return to their homes and come back only when they are very sick and smear positive. Then they are more likely to die. This is a very sensitive issue and needs to be handled carefully.”

CHILDHOOD TB
Childhood TB is another big challenge. We have a policy that all close contacts less than 15 years in family of a TB patient must undergo the Tuberculin Skin Test (TST or Mantoux test) but in practice it does not happen always. For example, in the TB surveillance data we had less than 10 TB patients below 15 years of age in the whole country. This means that perhaps TST is something that is not routinely practiced, and there might be some children with TB but they are not diagnosed. Childhood TB testing services are available at provincial level only which again acts a barrier.

TB-HIV and TB-DIABETES
Thailand practices TB and HIV collaborative activities. According to the WHO Global Tuberculosis Report 2012, there were 74% of TB patients with known HIV status and 59% received the ART during their TB treatment in 2011. The country has a policy that, although HIV testing is not mandatory, all TB patients should be given quality counselling and offered HIV testing services explaining the benefits of the test.

Thailand has yet to start building the system for TB diabetes collaborative activities, and design a package of guidelines comprising recording, reporting and training systems, and then implement it. The country usually does not have a project approach as the general belief is that sustainable interventions should be reflected in routine systems.

MULTIDRUG RESISTANT TB (MDR-TB)
There are a significant proportion of TB patients with a previous history of TB treatment, which later becomes MDR-TB. Only provincial hospitals are registered for MDR-TB care services and around 13 places in Thailand have the Gene Xpert diagnostic facility. Dr Sirinapha informs that, “In previous years we were not diagnosing enough of MDR-TB cases although they must have been there. But now we are doing lots of case-finding and so new MDR-TB cases in Thailand are likely to go up. We do not receive too many MDR-TB patients at our TB Bureau clinic here (which is a supranational lab), because we do DOTS here and so the patient has to be willing to come here every day. Currently about 10 MDR-TB patients and 100 TB (drug susceptible TB) patients are getting care from this clinic. Most patients who come here are often referred back to the hospital where they are registered with their insurance, as it is inconvenient for them to come to this clinic every day to receive treatment.”

RESEARCH FOR NEW TB DRUGS
Dr Sirinapha recognizes the importance of having better and safer drugs and effective vaccines for TB control. She says that, “Currently Thailand is not a site for TB vaccine or new drug studies. Two months ago the Research Institute for TB in Japan met our Director and invited Thailand as a site for clinical study of a new MDR-TB drug and now the application process is underway. If our application gets approved then Thailand will be a site for research and development of a new MDR-TB drug.”

HOME-BASED CARE Vs DOT
Dr Sirinapha likes the Home/Community Based Care model where patients can stay home, receive care and lead a normal life. She believes that, “Community-based care in TB has lots of advantages. Because then the community takes ownership and can help decide upon intervention options which are best suited to them. It is sustainable, and patients like it too as they take treatment at home or community level and go to work without too much of a hassle.”

“I think we can aim for zero TB infections and zero TB deaths, even though it might take some time. We have the right policies and programmes in place, and as of now we don’t have the problem with finances. So if we encourage people and motivate them then a lot of good things can happen in the next few years.”

Countries like India can learn lessons from Thailand where universal access to public healthcare is an important agenda on the election manifesto of political parties and where a political party had won the elections on the basis of proposing the health insurance scheme in its election manifesto.

Shobha Shukla is the Managing Editor of Citizen News Service - CNS. She is currently interviewing people dealing with MDR-TB in Thailand and other stakeholders, with kind support from the Lilly MDR TB Partnership and Global Alliance for TB Drug Development (TB Alliance). She is a J2J Fellow of National Press Foundation (NPF) USA. She received her editing training in Singapore, has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. www.citizen-news.org

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