Engaging hospitals to meet tuberculosis control targets in China: using the Internet as a tool to put policy into practice
Lixia Wang a, Xiaoqiu Liu a, Fei Huang a, Cornelia Hennig b, Mukund Uplekar c & Shiwen Jiang a
a. National Centre for Tuberculosis Control and Prevention, Chinese Centre for Disease Control and Prevention, Nanwei Road 27, Beijing, 100050, China.
b. World Health Organization, China Country Office, Beijing, China.
c. Stop TB Department, World Health Organization, Geneva, Switzerland.
Correspondence to Shiwen Jiang (e-mail: email@example.com).
(Submitted: 06 September 2009 – Revised version received: 13 May 2010 – Accepted: 14 May 2010 – Published online: 29 September 2010.)
Bulletin of the World Health Organization 2010;88:937-942. doi: 10.2471/BLT.09.071753
Engaging all relevant health-care providers in tuberculosis (TB) care and control through public–private and public–public mix approaches is an essential component of the World Health Organization's (WHO's) Stop TB Strategy.1 Public–private mix implies collaboration between the public sector and private care providers for delivery of TB care and control while a public–public mix means collaboration among different public sector entities within and outside the scope of ministries of health. China has used a public–public partnership between public hospitals and TB dispensaries as one of the strategies to reach the global TB control targets.2
According to the 2000 National TB Prevalence Survey in China, 94% of TB suspects reportedly went to “non-TB facilities”: 34% to general hospitals, 29% to township/village clinics, 22% to private clinics and 9% to traditional health clinics and other providers.3 Only 4.3% and 1.3% consulted a TB dispensary or a TB hospital. This finding was also corroborated subsequently by a social assessment study in four provinces.4 In 2003, the TB case detection rate in China was below the global TB control target of 70%. Two of the main strategies pursued by the Ministry of Health to improve the case detection rate were geographical expansion of DOTS (Directly Observed Treatment, Short course) strategy implementation and strengthening of the hospital–TB dispensary collaboration.
A window of opportunity opened in 2003 when China encountered a serious epidemic of severe acute respiratory syndrome. After this epidemic was brought under control, the Chinese government implemented a series of measures to strengthen its public health system.5 One of these measures was strengthening the surveillance of communicable diseases. The law on the control of infectious diseases was also revised, making it mandatory to report communicable diseases, including TB.
The National Centre for Tuberculosis Control and Prevention used this new tool to accelerate nationwide scale-up of hospital involvement in TB control. It carried out a pilot project of the Internet-based TB reporting and referral system with the cooperation of the China country office of WHO. This project demonstrated that collaboration between hospitals and TB dispensaries was feasible and that it enhanced TB case finding.6 Based on the evidence from the pilot project, the Ministry of Health issued an updated policy of collaboration between hospitals and TB dispensaries. The new policy stipulated that all pulmonary TB cases and suspects detected in general hospitals should be reported through the Internet and referred to TB dispensaries. The dispensaries must also trace the reported cases that fail to come to the dispensaries.
Based on data emerging from routine surveillance reports, this paper describes the processes and outcomes of collaboration between hospitals and TB dispensaries in China facilitated by the Internet-based TB reporting and management system.
The Chinese Ministry of Health has 17 departments. While control of communicable diseases is the responsibility of the Department for Disease Control, all hospitals fall under the Department of Medical Administration. The National Centre for Tuberculosis Control and Prevention under the Chinese Centre for Disease Control and Prevention provides technical support and routine management for national TB control programme implementation. This structure is replicated at provincial and prefecture levels. At the county level, most dispensaries that provide TB services are under the Centre for Disease Control and Prevention. Hospitals are required to report and refer TB suspects and cases to TB dispensaries.
In January 2004, China launched the world's largest Internet-based National Communicable Disease Information System. The purpose of the system was to provide a common platform for health facilities including general public hospitals to use the Internet to notify 37 communicable diseases, including TB, in real-time.7
As Fig. 1 shows, doctors in all health facilities, including hospitals, report information on TB suspects and cases through the Internet and refer them to the TB dispensary in the area. This information includes essential contact details and diagnostic status of each reported suspect and cases. It is available to authorized individuals and institutions as soon as it is entered into the system. TB dispensaries are required to record the arrival and confirmed diagnosis of all reported TB suspects and cases. If the referred suspects/cases do not arrive at the dispensary within one day, authorized staff members retrieve the relevant information from the system and trace the cases. Data quality is checked at different levels. Designated hospital staff members check the completeness and quality of reporting by different departments every day.
Fig. 1. Flowchart showing the policy on hospital–tuberculosis dispensary collaboration
At the TB dispensary, an assigned staff member checks the system every day for TB suspects/cases reported by hospitals. Steps in tracing non-reporting suspects/cases include telephoning the patient, tracking town or village doctors and, if required, visiting the patient at home. For each successful referral, the TB dispensary pays US$ 3 to the referring hospital. Township and village doctors are paid US$ 2 for every successfully retrieved patient while dispensary staff members earn US$ 1 for the same. A local “coordinating group” comprising officials from the local health bureau, hospitals and the TB dispensary guides, supports and supervises the implementation of the policy.
The financial resources for implementing this policy are provided by the government and international agencies. A central fund provides resources to all provinces to cover financial incentives for reporting and field-tracing. Expenses towards training, coordination meetings and telephone-tracing fees in 24 provinces are covered through a grant from The Global Fund to Fight AIDS, Tuberculosis and Malaria.
Data collection and analysis
The data for the analysis presented in this paper were collected from monthly and quarterly reports drawn from the routine TB surveillance system in China. Monthly reports are used specifically to monitor collaboration between hospitals and TB dispensaries on reporting, referring and tracing TB suspects/cases. The monthly reports submitted by all provinces from 2004–2007 were compiled and reviewed. These reports provide information on the number of TB suspects and cases reported, the number referred by hospitals, as well as the number arriving at the dispensaries on their own, by referral or after tracing. Since the monthly report data was limited, the quarterly reporting system was used to determine the number of confirmed TB patients among referred arrivals and the number of notified TB cases.
The following set of indicators was used to evaluate the process and the outcome of the collaboration: (i) proportion of hospitals participating in the Internet-based system; (ii) number of TB suspects/cases reported by the hospitals on the Internet and referred; (iii) proportion of TB suspects/cases whose sputum examination was reported by the referring hospitals; (iv) proportion of referred TB suspects/cases arriving at the TB dispensary without requiring tracing (referred arrival rate); (v) proportion of TB suspects/cases arriving at the TB dispensary after tracing (traced arrival rate); (vi) percentage of TB suspects/cases needing referral from hospitals who arrived in TB dispensaries with or without tracing (overall arrival rate); (vii) contribution of hospitals to case finding, i.e. proportion of TB cases from general hospitals among all TB cases registered in the national tuberculosis programme.
The reporting formats used routinely by provinces to send TB-related data to the central unit do not allow disaggregation of TB suspects and cases referred by hospitals. Similarly, disaggregating treatment outcomes of patients referred by hospitals and those presenting to dispensaries was not possible.
Combined data from the monthly and quarterly surveillance system was used to measure the outcome of each of the steps involved in improving the referral of TB suspects/cases to TB dispensaries. These included: participation of hospitals in the Internet-based reporting system; hospitals reporting TB suspects/cases through the Internet-based system and referring them to the TB dispensaries; the referred suspects/cases arriving at the dispensaries; dispensaries tracing those suspects/cases that fail to present; the traced and retrieved patients arriving at the dispensaries; and, as an outcome of all these steps, the overall contribution of hospitals to TB case finding in the country.
An increasing number of hospitals participated in the Internet-based reporting and referring system over the years, from 93.2% in 2004 to 96.0% in 2007. By 2007, 96% of the 9044 county hospitals and all 3007 TB dispensaries in the country were part of the Internet-based system. From 2004 to 2007, about 2.9 million TB suspects/cases were reported by hospitals through the Internet. In 2007 alone, hospitals reported about a million TB suspects/cases, more than twice the number reported in 2004 (Fig. 2).
Fig. 2. Cases of tuberculosis reported by hospitals in China, 2004–2007
Among the cases reported by hospitals, the number of smear-positive cases remained stable and the number of smear-negative cases rose slightly. However, the number of cases without sputum examination more than doubled. Importantly, the cases reported without sputum examination accounted for about 75% of all reported cases in 2007. The total number of referred TB suspects/cases who arrived at the TB dispensary also doubled from 2004 to 2007. However, the referred arrival rate remained almost constant (from 42.7% to 46.4%), (Fig. 3). The number of suspects/cases that needed to be traced by the TB dispensaries increased about fourfold over the period with a doubling of the tracing arrival rate (Fig. 4).
Fig. 3. Patients referred by hospitals to tuberculosis dispensaries in China, 2004–2007
Fig. 4. Patients arriving at dispensaries after tracing, China, 2004–2007
By 2007, the total number of suspects/cases arriving at and evaluated by TB dispensaries increased by more than 150% (from 273 582 to 707 284). The percentage of TB suspects/cases needing referral from the hospitals who arrived in TB dispensaries increased by over 33%, from 58.7% in 2004 to 77.8% in 2007 (Fig. 5). This increase was mainly due to improved tracing of referred patients who did not report to the dispensaries when first referred.
Fig. 5. Patients arriving at dispensaries after referral with or without tracing, China, 2004–2007
The collaboration between hospitals and TB dispensaries, enhanced by the Internet-based system, contributed substantially to the overall case finding. In 2007, about one third of all smear-positive TB cases notified were contributed by hospitals (Fig. 6).
Fig. 6. Contribution of hospitals to tuberculosis case detection in China, 2004–2007
As mentioned previously, data available from routine surveillance did not allow the disaggregation of treatment outcomes of patients referred by hospitals and those presenting to dispensaries. It was however reasonable to assume that the treatment success rates among patients referred by hospitals were unlikely to be inferior since the overall treatment success rates across the country remained consistently high before and after hospital involvement.
TB control and hospitals
The global target for tuberculosis control of detecting 70% of the estimated new sputum smear-positive cases was postponed in the year 2000 and not achieved in 2005.8 A major barrier to achieving the target in many countries has been limited engagement of large hospitals, both public and private, in TB care and control. In China and many other countries, most TB suspects, i.e. patients with a cough of long duration, first seek care at general public hospitals.
TB patients are not always managed well in hospitals. Typically, hospitals and hospital-based clinicians do not follow the recommended methods of TB management and they treat TB as any other medical condition rather than an important public health problem. There is a clinical–public health divide between the medical treatment of TB in hospitals and DOTS-based, patient-centred management in a health centre or dispensary. In China, as in most countries with a high burden of TB, the divide is vertical: at the top, the department or directorate responsible for hospitals is separate from that responsible for health centres or dispensaries and at the bottom there are few formal linkages between hospitals and health centres.9
Against this backdrop, the success of China's national tuberculosis programme is noteworthy. Since 2005, the collaboration between hospitals and TB dispensaries has been the main contributor to meeting and maintaining the global TB control targets of detecting at least 70% of new sputum-smear positive cases and curing 85% of them.10 One limitation has been the inability of the Internet-based system to determine the precise contribution of hospitals to the national TB case-detection rate.
The Internet-based system allowed monitoring of the process as well as the outcome of the hospital-dispensary collaboration. While increasing numbers of hospitals participated and TB suspects and cases referred by hospitals to TB dispensaries increased substantially, the number of patients acting on the hospital clinicians' advice and reporting to the dispensaries (referred arrivals) hardly increased (Fig. 3). The gains made in referrals (total arrivals) were all due to effective tracing of referred patients by the dispensary staff (traced arrivals) (Fig. 4 and Fig. 5). This remains a source of concern to the TB programme. Tracing so many patients results in an additional burden on the field staff, requires additional resources and, importantly, delays diagnosis and continues transmission of TB in the community. In the pilot period, we found that good health education provided to TB suspects and cases in hospitals contributes to a significant reduction in delay of diagnosis from 8.6 days in the pre-intervention period to 3.9 days after intervention.11 Increased workload of sputum smear microscopy on the laboratory staff due to a rapid and substantial increase in the number of suspects and a high proportion of smear-negative suspects have also been a matter of concern to the TB programme, with implications for supply of both human and financial resources.
Enablers and incentives
The Internet-based system required diverse inputs from the central and lower levels of government: enhanced government commitment and a conducive regulatory environment in the wake of the epidemic of severe acute respiratory syndrome, funding provision including financial incentives for hospital and dispensary staff, systematic training of hospital and dispensary staff, administrative commitment at the provincial level and a steering mechanism in the form of a local coordinating group. This paper based largely on the output from the routine surveillance system did not assess relative contribution of the varied interventions to the productive engagement of hospitals in TB control.
The issue of sustaining financial incentives to staff is important. The two functions for which financial incentives were provided – referral by the hospital staff and tracing by the field staff – produced impressive results.
The analysis presented here demonstrates successful adaptation of an Internet-based communicable disease reporting system to facilitate collaboration between hospitals and dispensaries for TB control. It also raises important questions that the national TB programme plans to address through further research and interventions. For any such system to work well on a sustainable basis, it has to be acceptable to all concerned – hospitals, dispensaries and patients. Some of the issues may need to be systematically addressed: do hospitals refer all TB suspects/cases to dispensaries? Why do hospitals increasingly send patients without giving sputum examinations? Why do a significant proportion of patients not report to dispensaries after referral? Will the dispensaries be able to bear the increasing burden of patient tracing? What happens to a large proportion of referred suspects that do not turn out to be TB?
Alternative strategies in setting up hospital–health centre collaboration for proper TB care and control could be either to strip hospitals of functions they do not traditionally perform well or to build their capacities to take on new tasks. In relieving hospitals of managing TB suspects and cases, the Internet-based system follows the former strategy. A middle path could be to compel hospitals to take on limited “clinical” tasks that they are well placed to carry out. For example, making a proper diagnosis, providing a correct drug prescription and supporting diagnosed patients with “public health” tasks such as notifying, counselling, record keeping, contact tracing, follow up and default retrieval. This seemed to have worked in large-scale projects in India and Indonesia.12,13 China's national TB programme has also been trying out a scheme of “designated hospitals” with encouraging results. In this scheme, a limited number of hospitals have been identified and strengthened to undertake high-quality TB management.
Strengthening health systems
The strength of China's Internet-based communicable disease reporting system is its integrated approach that combines reporting requirements of 37 important conditions. The TB programme has exploited the opportunity and the system to its own advantage. This successful example could well be adapted and applied in many countries. Other countries, including India,14 Republic of Korea15and Thailand, also have Internet-based systems that have helped improve TB surveillance and monitoring. It would be worthwhile to investigate additional benefits these systems may offer in detecting more cases earlier. Drawing lessons from this initiative in China, there is enormous scope to use advances in digital technology to adapt and set up new Internet-based systems, strengthen existing monitoring systems, integrate TB monitoring and surveillance into general disease surveillance and use Internet-based platforms to involve public and private care providers outside the TB control programmes.
Over the past decade, TB programmes worldwide have focused their attention on strengthening DOTS-based care at health centres in the hope that TB suspects and cases will not need to visit hospitals. Evidence that significant proportions of TB patients still continue to seek care from hospitals and other care providers requires that national TB programmes should cast their net wider and adopt a much broader “systems” approach that seeks to “engage all care providers”, as recommended by WHO's Stop TB Strategy.
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