Photo credit: Sophio Gokhelashvili

Photo credit: Sophio Gokhelashvili

Former Soviet countries in the Eastern European and Central Asian (EECA) region are fighting the prevailing perception that their outdated hospital-based tuberculosis (TB) programs are failing to provide patient-centered care. Since 2005, Georgia has emerged as the regional leader in decentralizing TB services and implementing country-wide directly-observed treatment (DOTS) coverage in line with the major components of the international Stop TB strategy.

Through several waves of healthcare reforms, former stand-alone TB dispensaries across the country, except the major cities, have become physically integrated into Primary Health Care (PHC) centers which are now owned by private providers who contract TB doctors (in Georgia—only phtysiatrists) and DOT nurses to deliver TB services as part of the TB state program. Universal access to diagnostic and treatment services is ensured and facilitated by demand-side incentives and robust monitoring and evaluation practices which are reflected in high 83%treatment success rate for all new and relapse cases registered in 2014.

However, the most challenging drug-resistant TB (DR-TB) remains Georgia’s Achilles heel, as no more than 43% of patients completed treatment successfully in 2013, and every third of them interrupted treatment in the past three years.

The latest TB adherence report in Georgia found that almost half of drug-resistant patients are lost to follow-up already by the 8th month of treatment. This figure is not surprising if we put ourselves in the shoes of patients who have to travel to TB units six days a week for at least 18 months (DOTS units are not within walking distance for most patients, and flexible programs like Video-Observed Treatment (VOT) have limited coverage under pilot schemes). Poor management of side effects from anti-TB drugs also contributes to dropouts. Ironically, hospitalized patients in the Tbilisi TB center are better off as they have access to medical specialists who manage their adverse reactions. In rural areas, patients do not always use general healthcare services, required to complement their TB treatment. Despite structural integration of TB services into primary care facilities, the vertical TB program is not linked with the PHC services. As a result, TB patients are not well informed about certain free general care services under the UHC program, and they avoid additional expenses associated with seeking specialists on their own. Grossly underpaid, TB doctors are discouraged to meticulously engage in holistic patient care which are required to support drug-resistant patients. Budding medical students see no appealing career path in phthisiatry either, so the numbers of TB specialists are declining. The shortage is already felt in some regions where only one TB doctor serves several districts. Lack of coordination between the TB program and primary care services exacerbates sub-optimal organization of TB services. While a TB doctor, family doctor and other specialists often occupy the same facility, they do not share patient records and rarely cross-manage co-morbidities. As a result, formal decentralization of TB services in rural and semi-urban areas falls short of providing country-wide patient-centered care: if you want to receive quality treatment, better go to the Tbilisi TB center. Although the government is committed to addressing these shortcomings, it is unclear whether a vertical program can cope with these challenges, even with further investments.

Drug-resistant patients require a flexible chronic care model which is more appropriate for the primary care level. Moreover, the declining TB epidemic will eventually phtysiatry redundant and the costly TB center unsustainable. This raises the question: how to uphold the benefits of holistic care offered at the primary care level without losing the capacity of a strong infection control vertical program? How much responsibility for TB care can family doctors successfully assume? Georgia has decided to test the feasibility of integrating TB services into primary care. Currently, I am here studying how such model could work.

I conducted a literature review on TB case management at the primary health care (PHC) level and found that integration of specialized TB services into general practice is now understood to be essential to patient-centered care.

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