Kazakhstan is embarking on an ambitious overhaul of its tuberculosis management program, shifting its emphasis away from in-patient to out-patient treatment, drawing on a wide network of technical support from partners including the Global Fund.
Although Kazakhstan is an upper middle income country, it has a considerable burden of multi-drug resistant TB, even though its indicators for TB are declining. One in three new cases of TB and one in two of the retreated cases diagnosed in the Central Asian nation are MDR-TB: partially attributable to the high rate of regional migration, co-infection with HIV and a substantial caseload among current and former prisoners.
But the high rate of MDR-TB, according to international as well as certain Kazakh medical experts, is also a function of the management system that has been in place since the Soviet era that requires between several months of in-patient treatment in designated TB wards at hospitals nationwide.
It was this high burden of drug-resistant disease and the country's ambitions to reform its management program that drove the Global Fund's decision to invite Kazakhstan to participate in the new funding model as an early applicant.
Kazakhstan's progress towards system-wide reform began in 2012 with new recommendations from the World Health Organization (WHO) about more effective, and cost-efficient TB management. The country's program commands a domestic approximate budget of $250 million annually, mainly calculated on a formula derived decades earlier during the Soviet era about the number of beds in each facility for TB patients.
The $39 million that Kazakhstan may access from the Global Fund over the allocation period through 2017 will help pilot an ambitious and innovative management of MDR-TB in four regions, shifting the burden of care away from the facility model towards a home-based, out-patient model. This will also widen the circle of stakeholders involved in TB management beyond government-employed health professionals to include the fledgling civil society actors in TB as well as international technical partners -- the Fund, as well as WHO and the World Bank.
Aidspan understands that while the Global Fund's financial contribution to Kazakh TB management is modest compared to the national budget, it is helping to trigger the reforms and assist the country in staying the course on its ambitious national agenda, informed by a national strategic plan developed in 2013.
The NSP had its genesis during a stakeholders meeting in May 2013 convened by the Global Fund. Also agreed during that meeting was a commitment to engage with civil society in order to ensure that the needs of vulnerable and key populations -- including former prisoners, and drug and alcohol abusers -- were addressed. A commitment for Kazakhstan to engage in cross-border control of TB in Central Asia was also extracted, as along with Russia it is the only country with the means to lead a regional initiative.
Eight months of country dialogue ensued and the NSP was submitted to government in December 2013: around the same time that the concept note for the Global Fund was submitted for review by the Fund's technical review panel (TRP). Official approval of the NSP was given in May 2014.
The result of these efforts, according to Mira Sauranbayeva, country director for Population Services International (PSI) in Kazakhstan, is the foundation for a new way of working. Rather than keeping TB patients confined to hospital for treatment, contributing to stigmatization and reluctance to adhere to treatment, an ambulatory response, allowing people to continue with their daily lives, will be promoted. Significant investment in the GeneXpert platform for rapid diagnosis of MDR-TB is also anticipated.
“The Global Fund program will help our country to pilot those innovative approaches in several regions and help to ensure that once donor support is phased-out, that government is ready to take over the responsibility to manage and sustain it,” she told Aidspan.
The new approach will produce cost savings because it will reduce extensive, and expensive hospital stays for TB patients. There will, however, be a need to ensure that these savings are reinvested in the fight against TB (laboratory, infection control, support to civil society and patients) and to develop a comprehensive training program for medical staff, who will now be conducting follow-up care at the community level and be engaged in community outreach.