Access to Quality Diagnosis and Rational Treatment for TB: Evidence from China – Gates Tuberculosis Control Project Phase III

Abstract Introduction: Over the last ten years, China has shifted the tasks of TB clinical care from the national TB control program to TB designated hospitals. Although China has successfully maintained a moderate reduction in TB incidence during this transition, China continues to face many challenges in improving the quality of TB diagnosis and treatment provided by the hospitals. The Chinese National Health Commission (NHC) and Chinese Center for Disease Control and Prevention (China CDC) collaborated with the Bill and Melinda Gates Foundation (Gates Foundation) to implement a China NHC- Gates Foundation Tuberculosis Control Project that aimed to scale up a comprehensive TB control model to improve the quality of TB care in three provinces (Zhejiang, Jilin and Ningxia). In this paper, we evaluate whether the China NHC-Gates Foundation TB project has helped improve access to quality diagnosis and rational treatment of TB. Methods: We selected 12 project counties as evaluation sites based on their economic development and TB notification status at the beginning of the project period in 2016. We conducted baseline and final evaluations in 2016 and 2019 respectively for data collection. We obtained TB patients’ information from the TB Information Management System (TBIMS) and reviewed medical records of TB cases to assess access to quality diagnosis and rational treatment at TB designated hospitals. We examined the change in coverage of different diagnostic tests for diagnosing TB and drug susceptibility, including sputum smear tests, culture, traditional DST and rapid molecular tests (RMT). We also evaluated the proportion of TB patients receiving adequate diagnostic services according to China’s National TB guidelines. For access to rational treatment, we evaluated the proportion of TB patients using unnecessary second-line drugs (SLDs) and the proportion of TB patients receiving adequate follow-up examinations during the entire treatment course. All indicators were analyzed by province. Results: Overall, we observed improved access to diagnosis on multiple indicators. The percentage of sputum smear-negative patients taking culture or rapid molecular tests (RMT) doubled between 2015 and 2018 (from 35% to 87%). The percentage of bacteriologically confirmed pulmonary TB cases increased from 36% in 2015 to 52% in 2018. RMT has been widely used and contributed an additional 20.3% of bacteriologically confirmed TB cases in 2018. The percentage of TB patients taking DST also doubled from 2015 to 2018 (from 40% to 82%) while the proportion of TB patients receiving adequate diagnosis services increased from 88% in 2015 to 96% in 2018. Among all smear-negative TB patients, over 86% received the recommended diagnostic services at the end of the study period, an improvement from 75% prior to project implementation. Asymptomatic smear-negative TB patients’ diagnosis quality improved even more: 63.1% received the recommended services in 2018, a massive improvement from only 18.2% prior to the project period. Although the proportion of patients receiving recommended follow-up tests during the entire treatment course improved, the proportion of TB patients treated by unnecessary SLDs increased from 12.6% in 2015 to 19.9% in 2018. Despite progress, regional disparities remain among the provinces, albeit the gaps between them narrowed down for almost all indicators. Conclusions: Our study found that between 2015 to 2018, access to quality TB diagnosis and follow-up services has been improved substantially in the study sites, primarily due to the implementation of the China NHC- Gates Foundation Tuberculosis Control Project. Despite progress, irrational use of SLDs remains a problem because of perverse financial incentives given to the hospitals.