By Olena Trush and Olena Kheylo
In the 21st century, tuberculosis (TB) remains a considerable problem in Ukraine and around the globe. Ukraine is among the 27 countries with the highest multi-drug-resistant TB burden in the world, largely because priority is given to hospital-based TB treatment; TB care is financed through a rigid methodology based on the number of occupied hospital beds; provision of directly observed therapy is lacking, and patient social support is limited.
Despite strong TB-related international technical assistance and international funding of TB control programs, Ukraine has not fully and adequately implemented international recommendations. There is still a need to reduce hospitalization for TB patients, widely apply ambulatory TB treatment, and implement patient-centered approaches with integrated medical and social services as well as essential patients’ support. However, the current economic crisis and ongoing health reform in Ukraine are challenging the old-fashioned hospital-based TB services in Ukraine so much that the idea of ambulatory treatment is becoming more acceptable to health authorities.
Exploring a more flexible model of TB care
To take advantage of this shift in thinking, the USAID Strengthening Tuberculosis Control in Ukraine (STbCU) Project conducted a survey to identify effective approaches to TB and TB/HIV outpatient care in terms of healthcare service integration at the primary healthcare level.
The resulting data suggested that the outpatient model of TB care, excluding cost of medications, chemicals, diagnostic services, and patient-covered costs, is approximately five times less expensive than the model combining inpatient and outpatient care. Furthermore, 78 percent of outpatients adhered to the protocols as opposed to only 54 percent of patients under the combined model.
Through this evaluation, the project aimed to collect evidence to justify scaling effective outpatient care models in the pilot region, Kryvyy Rih. Based on the data, health administration officials in the pilot area also became interested in evaluating the model further. STbCU gained approval to conduct a full pilot to confirm the results and further evaluate health outcomes.
Designing the pilot with decision-makers in mind
The pilot focused on shifting from routine combined inpatient/outpatient care to an existing but improperly implemented ambulatory TB treatment model. While working on the pilot, the researchers’ goal was not only to assist local health authorities who were eager to achieve better results in TB control, but also to advocate for more effective approaches in TB control at the national level. Researchers identified and included international best practices in TB control in the pilot, as well as the capabilities of the local TB and primary healthcare system in order to avoid staff overload.
The results: Ambulatory care is equally effective at lower cost
During the pilot, 67.7 percent of patients completed the full course of outpatient treatment. This number includes both smear negative and smear positive patients. The rate of effective treatment in the intervention group was 79 percent, versus 76.3 percent in the control group; that is, it remained almost unchanged despite an almost two time reduction of hospitalization (Figure 1). Moreover, the death rate in the intervention group was twice as low (9.7 percent versus 15.8 percent). In addition, patient interviews showed that there was no statistically proven difference in adherence to treatment between the control and intervention groups. This means that treatment models do not influence TB patients’ adherence to treatment.
Figure 1. Treatment models and treatment effectiveness in control and intervention groups of patients.
As expected, TB/HIV co-infected patients were the group which benefited most from home-based treatment, as this group is most vulnerable during hospital treatment. The treatment effectiveness rate in the intervention group was 73.1 percent versus 64.7 percent in control group and the death rate was 19.2 percent versus 35.3 percent, accordingly. Antiretroviral treatment (ART) coverage increased from 53 percent in the control group to 80 percent in the intervention group. It is also noteworthy that only 9.3 percent of TB/HIV patients in intervention group refused ART (before the pilot such rates reached 43 percent).
The pilot results also discredited the fear of TB transmission among household contacts: at the time of initial examination, TB was detected in 2 percent of contacts (simultaneous detection). Dynamic monitoring in combination with drug prophylaxis resulted in detecting no other TB cases among contacts during the pilot.
Overall, the conclusions of the pilot were that:
- Wide implementation of ambulatory treatment for TB patients is the best alternative to the combined inpatient/outpatient treatment model, and provides the same effectiveness at lower cost.
- The medical system in Ukraine can easily cope with rolling out TB ambulatory treatment without any objective obstacles.
Using data to change policy around TB care
The results of the pilot convinced the majority of stakeholders not only in the field of TB control but in the Ukrainian health system as a whole of the necessity of shifting to the TB ambulatory model. As a result of joint efforts to advocate for TB ambulatory treatment, the Ukrainian Ministry of Health abolished the order on per-bed funding and staffing of the medical system in September 2016. Now, the way is opened for appropriate planning of resources to expand TB ambulatory treatment and make local TB control programs much more cost-effective.
The success of this pilot represents the intersection of evaluation use and evaluation design. While the proposed TB care models were based on accepted international standards, the type of data necessary to change minds required an evaluation design that took into consideration local and even hyper-local expectations and context. An iterative evaluation-centric approach was able to speak to the specifics of the Ukrainian TB treatment system. The small initial survey generated enough data and interest to achieve buy-in for an expanded pilot with more rigorous data collection. The STbCU experience can serve as a model to other international and cross-cultural evaluations by demonstrating the utility of designing different stages of evaluation with the end user and decision-makers in mind.Olena Trush is the monitoring and evaluation specialist and Olena Kheylo is the senior technical advisor for the USAID Strengthening Tuberculosis Control in Ukraine (STbCU) Project.