One of the United States Agency for International Development’s (USAID’s) commitments under the National Action Plan for Combating Multidrug-resistant Tuberculosis (NAP) Objective 2.2, “Prevent MDR-TB transmission,” Sub-objective 2.2.2, “Enhance adherence to [tuberculosis] TB and [multidrug-resistant tuberculosis] MDR-TB treatment” is to “develop generic ancillary care packages (e.g., services and/or supplies not directly related to treatment, but that enable patients to continue therapy, such as pain or nausea medicine, food rations, supportive services) for MDR-TB patients.” USAID’s milestones under this Sub-objective are to develop this care package by the end of Year 1 and implement it in up to 10 priority countries with high burdens of MDR-TB by Year 3 of the NAP, or 2018. The 10 priority countries are Burma, China, India, Indonesia, Kazakhstan, Nigeria, Pakistan, Philippines, South Africa, and Ukraine.
This report describes the results of the pilot implementation of the Care Package initiated in 2017 and completed by the end of 2018. After the development of Care Package framework in November 2016, it was decided to field test the concepts described in the Package and measure effectiveness, feasibility, and acceptability of interventions, as well as to capture cost and cost-benefits. The pilot was implemented in four countries (China, Pakistan, South Africa, and Ukraine) to test the approach and refine it prior to introduction to all 10 priority countries in September 2018.
Implementing a comprehensive care package for people with DR-TB using the framework developed through this project provides a standardized yet adaptable approach to delivering patient-centered services. At the interim outcome stage, it shows lower levels of adverse outcomes and higher levels of patients remaining on treatment, with a reasonable expectation that final treatment outcomes will also be improved over those from standard care. Using modeling to predict final outcomes and calculate the costs of implementation versus the benefits in the long run, implementing the care package produces better benefit-to-cost ratios in all of the settings where it was piloted, representing diverse health systems and patient populations.
From a health systems perspective, this approach is both feasible and acceptable to implement, with wide support among frontline providers but lingering questions about sustainability in some settings. The benefits overall, in terms of lives saved, secondary cases prevented, and economic gains realized make a convincing argument that national TB control programs and their partners should consider implementing a patient care package for people with DR-TB, with the possible expansion to all people with TB who are at risk of not completing their treatment.