Case Study of National Tuberculosis Programme Implementation in Nepal

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					 Case Study of
    National
 Tuberculosis
  Programme
Implementation
    in Nepal
October/November 2002

      Neil Hamlet,
   Sushil Chandra Baral

     World Bank
 Short Term Consultants
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                                       Page 2


                                                          Contents
List of Abbreviations and Acronyms .............................................................................. 4
Executive Summary .......................................................................................................... 6
  Study context .................................................................................................................. 6
  Review process ............................................................................................................... 6
  Tuberculosis control in Nepal......................................................................................... 6
  The NTP and lessons for the Nepal health sector ........................................................... 6
  The NTP and health sector reform.................................................................................. 7
  Partnerships and resourcing of the NTP ......................................................................... 7
  Local application of the DOTS strategy – lessons for the region ................................... 8
Introduction....................................................................................................................... 9
  Study terms of reference ................................................................................................. 9
  Linkage to other areas of research .................................................................................. 9
  Methodology ................................................................................................................... 9
  Constraints ...................................................................................................................... 9
Background information ................................................................................................ 10
  Country profile.............................................................................................................. 10
  National health situation ............................................................................................... 11
  The status of TB control in Nepal................................................................................. 13
  Development of the health policy agenda in Nepal ...................................................... 15
  Millennium Development Goals................................................................................... 18
  Local Self Governance Act (1999) ............................................................................... 18
  The Health Sector Reform Process in Nepal ................................................................ 18
  The Nepal Health Sector Strategy - An Agenda for Change ........................................ 19
  NTP and the current security situation ......................................................................... 20
  The National Tuberculosis Control Programme ........................................................... 21
Lessons for the Nepal Health Sector ............................................................................. 25
  Leadership..................................................................................................................... 25
  Strong team approach ................................................................................................... 25
  Staff motivation ............................................................................................................ 25
  Communication............................................................................................................. 26
  Peer review.................................................................................................................... 26
  Sharing of best practice................................................................................................. 26
  Central policy – local innovation.................................................................................. 27
  High quality technical support ...................................................................................... 27
  Focused and consistent external donors........................................................................ 28
  Partnership working ...................................................................................................... 28
  Appropriate and phased decentralisation ...................................................................... 28
  The formation of action – orientated, structured networks........................................... 29
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                                        Page 3


   Summary of key ‘success factors’ ................................................................................ 30
   Negative factors ............................................................................................................ 30
   New areas for attention ................................................................................................. 31
The Impact of Health Sector Reform............................................................................ 32
  Background ................................................................................................................... 32
  Health Sector Reform in Nepal..................................................................................... 33
  Summary ....................................................................................................................... 38
  Introduction:.................................................................................................................. 40
  NTP Budgeting ............................................................................................................. 40
  Securing political support and government funding..................................................... 41
  Attracting external donor support ................................................................................. 41
  Mechanisms for funding provision: .............................................................................. 42
  Donor base profile: ....................................................................................................... 42
  The ability of the NTP to use ‘released funds’ ............................................................. 44
  The prospects for the next 5 years ................................................................................ 44
  The positive and negative implications of the HSR process on sustained resourcing
  of the NTP..................................................................................................................... 45
  Recommendations regarding NTP funding................................................................... 45
Lessons for the Region.................................................................................................... 46
  Success factors .............................................................................................................. 46
  Additional Key Operations ........................................................................................... 49
Thanks.............................................................................................................................. 52
Annexes ............................................................................................................................ 53
 Annex 1: Terms of Reference ....................................................................................... 54
 Annex 2: Map of Nepal................................................................................................. 55
 Annex 3a: Organisational chart of Department of Health Services.............................. 56
 Annex 4: Tables, Graphs and Figures........................................................................... 59
 Annex 4a: NTP 5 - year budget summary 1998-2003 .................................................. 60
 Annex 4b: HMG Finance Ministry (Red Book) budget figures 1998-2003................. 62
 Annex 4c: Contribution of JICA................................................................................... 63
 Annex 4d: Contribution of LHL ................................................................................... 63
 Annex 4e: Contribution of NORAD ............................................................................. 64
 Annex 4f: Contribution of DfID ................................................................................... 64
 Annex 4g: Contribution of WHO.................................................................................. 65
 Annex 4h: Epidemiological assumptions of NTP 5-year plan 1998-2003 ................... 67
 Annex 4i: TB Case notification in Nepal 1972-2002 ................................................... 68
 Annex 6: List of background materials examined ........................................................ 70
 Annex 7: List of external peer reviewers...................................................................... 72
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 4




List of Abbreviations and Acronyms
ARI                        Annual Risk of Infection
BNMT                       Britain Nepal Medical Trust
CBO                        Community based organisation
CCC                        Central Chest Clinic
CTLHP                      Community TB and Lung Health Project
DfID                       Department for International Development, UK
DHO                        District Health Officer
DoHS                       Department of Health Services
DOTS                       Directly Observed Treatment Short-course
DTLA                       District TB/Leprosy Assistant
EDPs                       External Development Partners
EHCS                       Essential Health Care Services
FCHV                       Female community health volunteers
GENETUP                    German Nepal Tuberculosis Project
HEFU                       Health Economics & Financing Unit
HeSo                       Centre for Health and Social Development, Norway
HMG                        His Majesty’s Government of Nepal
HSR                        Health Sector Reform
INF                        International Nepal Fellowship
INGO                       International Non-governmental organisation
I-PRSP                     Interim Poverty Reduction Strategy Paper
IUATLD                     International Union Against TB and Lung Disease
JAT                        Japanese Advisory Team
JICA                       Japanese International Co-operation Agency
LHL                        Norwegian Heart and Lung Association
LMD                        Logistics & Management Division
MCHW                       Maternal and child health worker
MDGs                       Millennium Development Goals
MoH                        Ministry of Health
MTEP                       Medium Term Expenditure Programme (or Framework)
MTSP                       Medium Term Strategic Plan
NATA                       Nepal Anti-TB Association
NGO                        Non-governmental organisation
NHS                        National Health Service, UK
NIH                        Nuffield Institute of Health
NLR                        Netherlands Leprosy Relief Association
NORAD                      Norwegian Government Aid
NTC                        National Tuberculosis Centre
NTP                        National Tuberculosis Programme
PHC                        Primary Health Care
QC                         Quality control (microscopy)
QCA                        Quality control assessors
RCT                        Randomised controlled trial
RIT                        Research Institute of Tuberculosis (Tokyo, Japan)
RMS                        Regional Medical Stores
RTC                        Regional TB Centre (Pokhara, Western Region)
RTLA                       Regional TB/Leprosy Assistant
SAARC                      South Asian Association for Regional Co-operation
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 5


SCC                        Short Course Chemotherapy
SEARO                      WHO South East Asia Regional Office
SLTHP                      Second Long Term Health Plan
STC                        SAARC TB Centre
SWAp                       Sector Wide Approach
TAG                        Technical Advisory Group
TB                         Tuberculosis
TBCP                       TB Control Project
TLP                        Tuberculosis Leprosy Project (INF)
ToT                        Training of trainers
TQM                        total quality management
UMN                        United Mission to Nepal
VDC                        Village development committee
VHW                        Village health worker
WHO                        World Health Organisation
YUHP                       Yala Urban Health Programme (UMN)
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 6




Executive Summary
Study context
The National TB Programme (NTP) of Nepal is generally regarded as highly
successful both nationally and internationally. The programme has never previously
been studied to identify the key success factors both from the perspective of technical
TB control implementation and generic health service functions. The impact of Health
Sector Reform (HSR) on programmes such as TB control is a live topic of debate
internationally and also in Nepal where an HSR process is currently in the late stages
of planning. From these two perspectives Nepal provided an ideal case study
opportunity to examine the NTP in the climate of imminent HSR. This work was
commissioned by the World Bank.

Review process
Two short-term consultants (one national, one international) with considerable
working experience of TB control in Nepal were contracted to undertake the review
over a two-week period in late autumn 2002. Information was gathered by interviews,
site visits, correspondence and the examination of relevant documentation (in
English). The world literature on HSR and TB control was explored to provide a
framework for the work. The document was peer-reviewed prior to publication.

Tuberculosis control in Nepal
TB causes an estimated 8,000-11,000 deaths per year in Nepal. In the year 2000/01
over 31,000 TB patients were registered and treated under the NTP, of which 13,000
were new smear positive. The NTP was revised in 1995 and DOTS implemented in
1996. By mid-2001 the DOTS strategy had been rolled out to 227 treatment centres
with 684 sub centres, covering 84% of the total population across all 75 districts in
the country. Treatment success rates of 85% or greater have been reported over the
past 5 years.

The NTP and lessons for the Nepal health sector
Examination of the Nepal TB Programme provides insights of value across the health
sector in terms of generic issues such as programme management, organisational
culture and implementation practices.

The areas highlighted as being key success factors were:

     Leadership and a strong team approach
     Staff motivation
     Communication
     Peer review practices including the sharing of best practice
     A clear central policy but encouraging local innovation
     High quality technical assistance at national and regional level
     Focused and consistent external donor partners
     Partnership working practices
     Appropriate and phased decentralisation
     The formation of action-orientated structured networks
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 7


The NTP and health sector reform
The overarching objective of HSR is threefold: to maximise efficiency, equity and
quality. The process involves the defining of priorities, the refining of policies, and
the reforming of institutions through which these policies are implemented.
His Majesty’s Government of Nepal (HMG) have set three programme outputs which
will be at the core of the Nepal HSR programme over the next 5 years. These are an
Essential Health Care Service (EHCS) package, decentralisation, and a public-private
mix of service provision.
The potential of the NTP to champion, or conversely, to hinder HSR change is
addressed together with an analysis of the impact that HSR may have on the delivery
of TB control. The eight Nepal HSR outputs and seven key areas identified by the
TB/HSR literature are used as a template against which to evaluate the Nepal
situation.
The strengths of the NTP in relation to maintaining quality TB control services during
the HSR process are; the commitment to widespread advocacy, the close monitoring
of anti-TB drug procurement and delivery, the retention of technical supportive
structures for microscopy services and trimesterly cohort reporting mechanisms, the
emphasis on service delivery through the PHC system and the awareness of ‘NTP’
donor partners of the HSR process.
The weaker aspects are a lack of pro-active participation of the NTP in the reform
planning process, no evidence of advance planning to prepare for the implications of
HSR on TB control programming and an absence of plans to pilot test the new
institutional arrangements arising from the HSR process.



Partnerships and resourcing of the NTP
One of the successful features of the Nepal NTP has been the ability to negotiate
effective working partnerships and attract the required resources both financial and
technical to implement an expanding programme of work. The preparation of detailed
and budgeted 5-year development plans has been the foundation of this success.
Sustained political and media advocacy has secured widespread awareness and
support of the programme both nationally and internationally. An external review of
the programme in 1994 became the catalyst for the revised NTP and led to a strong
working partnership between the programme, external donors and a number of
established in-country international development NGOs. Much of the non-
government support provided to the NTP is in the form of technical assistance,
training, supervision and service delivery mechanisms which are not currently
quantified in NTP budgets. Currently therefore only an estimate can be made of the
true resource envelope required for the NTP. Additionally not all financial flows are
documented in the Ministry of Finance annual budget known as the ‘Red Book’.
The NTP has demonstrated excellent capability to utilise government development
budget ‘released funds’. This is a measure of the planning and implementation
capacity of the programme. The sustainability of the current donor and implementing
partner INGOs for the next 5-year phase requires exploration as two of the regional
counterpart INGOs are currently undergoing restructuring. Additional challenges lie
in the expected impact of HIV and the increasing attention being given to the
syndromic approach to adult lung health.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 8



Local application of the DOTS strategy – lessons for the
region
A major component in the success of the adoption of the DOTS strategy in Nepal lies
in the structured and phased manner in which the key operations for implementation
were addressed. Using the 2002 WHO publication DOTS Framework for Effective
TB Control as a template the lessons for other TB programmes in the region are
defined. These are summarised as:
    Provision of adequate central unit office facilities for the NTP.
    A robust national review in 1994 leading quickly into the preparation of a
    development plan.
    Choice of external consultant is important as is the continuity of leadership of the
    NTP director in the period of any major revision of the NTP.
    A well developed national TB manual prepared in advance of any implementation.
    The introduction of the cohort based TB reporting documentation requires to be
    handled as a project in itself.
    The availability of adequate financial resources to back a comprehensive, locally
    adapted, rolling training programme.
    The widespread use of the WHO training modules to increase technical capacity
    for senior staff and trainers.
    The expansion of training into generic health care support roles and wider civic
    society.
    Recognition of the crucial importance of available microscopy services for a
    functioning DOTS programme.
    The DOTS expansion programme consisted of a comprehensive package of new
    site selection and preparation based on the 10-point checklist.
    Public (PHC and hospital), private and NGO facilities were used for service
    delivery.
    The management of drug supply has been closely monitored and controlled by the
    central unit providing the fast expanding programme with the security of
    uninterrupted supplies.
    The supervision programme is an example of excellent partnership working
    between government staff, ring fenced donor support, and local capacity building
    by ’on the ground’ INGOs.
    The emphasis on proactive communication and networking at all levels was
    instrumental in the success of the programme.
    The partnership working between the NTP and the press provided wide local and
    national press and radio coverage, increasing awareness of, and confidence in,
    public attitudes towards TB and its treatment.
    The Nepal programme had a culture of working with different agencies in the
    control of TB which promoted the inclusion of new private and voluntary
    partners.
    The NTP has effectively resourced external assistance in the process of budget
    formulation and achieved good release of funds.
    The attention given to practical operational research has driven up technical
    capacity of both individuals and the programme as a whole.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 9


Introduction
Study terms of reference
Purpose: To produce a case study analysis of the NTP in Nepal with the following 3
specific objectives:
1. To provide lessons for public health, primary care and health sector development
   in Nepal based on the successes and remaining challenges of the NTP and its
   integrated service delivery system.
2. To assess the level of funds available for the NTP from public and external
   sources, historical trend, assurance of financing for the next 3-5 years.
3. To summarise lessons for other countries on local adaptation and application of
   the recommended TB control strategy known as DOTS.
The complete terms of reference are in annex 1.

Linkage to other areas of research
The Tuberculosis Strategy and Operations Unit in the Stop TB department of WHO is
currently proposing to initiate a systematic review in 3 countries in collaboration with
the Centre for Health and Social Development (HeSo), Norway. The countries
selected are Nepal, Tanzania and Uganda. The purpose of this larger work is to
explore the evidence as to how and to what extent vertical programmes contribute to
or interfere with health system development.
This World Bank Report will complement this evidence base by providing a case
study approach to overlapping issues.


Methodology
Information was collected over a 2-week period in Nepal. The dates coincided with
those of an international review team who undertook an in-depth technical assessment
of the TB programme. This allowed the authors to gain valuable access to related
documentation, interviews with key international and national review team members
and participate in the briefing and field report meetings. Documentation was obtained
from a wide variety of sources including World Bank, Ministry of Health, External
Donor Partners and local implementing INGOs. Semi-structured interviews were
conducted across a wide range of stakeholders. Drafts of the report were peer
reviewed by selected international experts and local key stakeholders (see annex 7).


Constraints
The consultants were scheduled to join one of the review field teams however this had
to be cancelled at short notice due to lack of security clearance. Interview
appointments were difficult to schedule at short notice particularly with senior
government health officials. This problem was compounded by a national strike day.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                Page 10




Background information
Country profile
Nepal is a landlocked country lying along the Himalayan chain. Rectangular in shape,
the country is 885 kilometers in length (east to west) and 193 kilometers in width
(north to south). It shares its northern border with the Tibetan autonomous region of
the People’s Republic of China and its eastern, southern, and western borders with
India. The total land area is 147,181 square kilometers and the population, according
to the 2001 Census preliminary report, is approximately 23.2 million. The population
has doubled in 30 years. The population growth rate increased from 2.1 in 1971 to 2.6
in 1981, then declined to 2.1 in 1991.1 The population density has doubled over the
last three decades from 79 persons per square kilometer in 1971 to 158 persons per
square kilometers in 2001. Nepal is predominantly rural; nevertheless, the urban
proportion has increased steadily over the last 30 years, from 4 percent in 1971 to 14
percent in 20012.
Topographically, Nepal is divided into three distinct ecological zones. These are the
mountains, hills and terai (or plains). Of the total population, 49% live in the terai,
44% in the hills, and 7 % in the mountains. For administrative purposes, Nepal is
divided into 5 development regions, 14 zones and 75 districts. Districts are further
divided into village development committees (VDCs) and urban municipalities. At
present, there are 3,914 VDCs and 58 municipalities in Nepal. Nepal is a multi-ethnic
and multi-lingual society. The 1991 Census identified 60 caste or ethnic groups and
sub groups of the population and 60 different languages or dialects prevalent in the
country.
Nepal’s economic development has been severely constrained by challenging
geographic, topological and socio-cultural environments. Latterly the unstable
political situation has further fuelled the difficulties facing the nation. Nepal is
defined as a poor country where the estimated per capita gross domestic product
(GDP) for the year 1999/2000 is US $244. About 80% of Nepalis rely on agriculture
for their livelihood. Forty-eight percent of GDP comes from the service sector, 42%
from the agricultural sector and the remaining 10% from manufacturing.3

Table 1: Basic Demographic Indicators
Indicator                    1971 Census                  1981 Census          1991 Census   2001 Census
Population (millions)                       11.6                15.0                  18.5       23.1
Increased growth rate (%)                   2.1                  2.6                   2.1        2.2
                   2
Density (pop/km )                            79                  102                   126        158
Percent urban (%)                           4.0                  6.4                   9.2       14.2
Life expectancy (age)
       Male                                 42.0                50.9                  55.0     Unknown
       Female                               40.0                48.1                  53.5     Unknown
Source- Central Bureau of Statistics 1995 and 2001




1
  Central Bureau of Statistics, 1995
2
  Central Bureau of Statistics, 2001
3
  Ministry of Finance, 1996
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 11


National health situation
The overall goal of health care in Nepal is to improve the health situation of the
people providing them with preventive, supportive, curative and rehabilitative health
care services and provide support for poverty alleviation.
The population is diverse in Nepal. The mountainous terrain and geographic
conditions isolate the primary rural population, many living below the poverty level.
Such conditions provide a particular challenge to providing health care to all. As in
many countries it is difficult to persuade health staff to work in the rural and remote
areas and this is reflected in staffing of His Majesty’s Government (HMG) health
facilities. In addition NGOs and private health care providers are concentrated in the
better-off regions of the country.
Estimates of Nepal’s relative burden of disease were undertaken in 1997. The ‘burden
of disease’ study indicated that infectious diseases, nutritional disorders and problems
related to reproduction dominate the overall pattern of morbidity in Nepal. The main
causes of death and disability are infectious and parasitic disease, perinatal and
reproductive health problems. The highest risk groups are children under five,
(particularly females who accounts for 52.5% of all female deaths) and women of
reproductive age.
The burden of disease study estimates emphasised that the needs of children and
mothers are not adequately met by the existing health delivery system.
In the case of adult males (15-44 years), tuberculosis (TB), accidental falls, acute
respiratory infections (ARI) and motor vehicle accidents were the leading causes
contributing to the burden of disease for that age group. For females in the same age
group the burden of disease was attributed to maternal disorders, tuberculosis, burns
and major affective disorders. There is evidence of an increase in newly emerging and
re-emerging diseases namely; malaria, kala-azar, Japanese B encephalitis,
tuberculosis and HIV-AIDS.
The issue of equality of access to health care compounds the impact of the burden of
disease. In Nepal the major equity issues relate to gender, age, caste, ethnic group,
income and area of residence (urban, rural, mountain, hill & terai). Transport costs are
a significant deterrent to the poor in accessing health care in the remote areas.
Despite such shortcomings Nepal has made significant improvement in some health
care indicators during past years as a result of planned development. The child
mortality rate has decreased from 107 per 1,000 live births in 1987 to 64 per 1,000
live births in 2000 and the maternal mortality has also decreased from 580 per
100,000 live births to 539 during the same period.4 Similarly the user percentage of
family planning devices has increased from 3% in 1976 to 39% in 2001. There has
also been considerable progress in the provision of childhood vaccinations,
tuberculosis and leprosy control, malaria, kala-azar, and diarrhoea control
programmes.
However, the health care indicators show that overall the health care service has not
progressed satisfactorily in Nepal in comparison to other countries. A summary of the
progress made in the health sector is provided by the report of the Ninth Development
Plan which spanned the period 1997 – 2002.




4
    DHS Statistics of 1996
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                       Page 12



Table 2: Target and Progress of the Health Sector during Ninth Plan (1997-2002)

                                                                        Target and progress of the
                                                                        health sector during ninth plan
Health Indicators
                                                                                           Progress achieved
                                                                        Target
                                                                                           by 2002

Coverage by basic health services (%)                                        70                   70
Maternity services provided by trained workers (%)                           50                   13
Family planning device users (%)                                            36.6                  39
Total period fertility rate (live births per woman)                         4.20                  4.1
Crude birth rate (live births per 1000 total population per                 33.1                  34
annum)

Infant mortality rate (deaths from 1st day of life to end of 1st            61.5                  64
year of life per 1000 live births per annum)

Child mortality rate (per 1,000 live births per annum)                     102.3                  91
Maternal mortality (per 100,000 live births per annum)                      400                 539**
Crude death rate (deaths per 1000 total population per annum)                9.6                  10
Life expectancy (years)                                                      59                   59
Total hospital beds (government and private)                                  -                    -
          Government                                                          -                  5023
          Non-government                                                      -                    -
Primary health centres                                                        -                   160
Health posts                                                                  -                   710
Sub-health posts                                                              -                  3167
Skilled human power                                                           -                 24800
Number of women health workers                                                -                    -
Number of hospital including district, zonal, regional,
                                                                              -                   85*
sub-regional, Ayurvedic and central hospitals
* Hospitals under the Ministry of Health only;      ** According to Nepal Demographic and Health Survey of 1996
Source: HMG, MoH Tenth Health Plan 2002
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002            Page 13



The status of TB control in Nepal
Tuberculosis is one of the foremost public health problems in Nepal, causing a
significant burden of morbidity and mortality. About 45% of the total population is
infected with TB, out of which 60% are adults (aged 15-64). Every year, 44,000
people develop active TB, of whom 20,000 have infectious tuberculosis. TB causes an
estimated 8,000-11,000 deaths per year5. In the year 2000/01 over 31,000 TB patients
were registered and treated under the NTP, among them about 13,000 are new smear
positive1.
Case notification
Since the implementation of DOTS, case notifications of new smear positives have
increased. This is a reflection of the increased coverage of the revised NTP
implementing the DOTS strategy.



                                          Case notification trends in NTP
                           16,000
                           14,000
                                         DOTS implementation
          Cases notified




                           12,000
                           10,000
                            8,000
                            6,000
                            4,000
                            2,000
                                0
                                    1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01
                                             No.Cases New P+                    No.Cases New P-ve
                                                                     year
                                             No. Cases EP                       No. Cases Retreat

Figure 1. Case notification trends in NTP (new smear positive cases only)
Source: Annual Report of NTP 2000/01


Treatment outcome
Treatment outcome under NTP seems sustainable and increasing after implementation
of DOTS strategy. In 1996 DOTS was limited only in four centres. By July 2001
DOTS expanded to 227 treatment centres with 684 sub centres, covering 84% of total
population in 75 districts. According to the NTP annual report global target of
treatment success 85% has been achieved by NTP under DOTS strategy.




5
 Annual Report of National Tuberculosis Control Programme, National Tuberculosis Centre, Nepal
2000/2001
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002             Page 14




                                             Treatment Outcomes in NTP
                  100%
                    80%
                    60%
                    40%
                    20%
                     0%
                                   1996/97              1997/98             1998/99        1999/00    2000/01
       T.Out                           4                   32                  22            54          72
       Defaulted                      10                  109                  201          250         570
       Died                            7                   62                  49           285         512
       Failure                         4                   26                  148           86         128
       Treatment success             264                 1542                 3050          4849       8396

Figure 2: Treatment Outcomes in NTP by annual cohort analysis
Source: NTP annual report 2002

TB and HIV
Four surveillance surveys of HIV infection among patients with TB have been
undertaken in Nepal. The results of the surveys show an increasing trend of HIV
infection among patients with TB from 0% in 1993/94 to 2.44% in 2001/2002. The
survey indicates that 84% of HIV-TB co-infections occur in men between the age of
25 and 55 years.
MDR TB
Since 1996 surveillance of anti-tuberculosis drug resistance has been conducted with
the co-operation of the World Health Organization, NTC and GENETUP. Latest anti-
tuberculosis drug resistance survey shows ‘any resistance’ at 16.5% (11.0% in new
cases and 40.9% in previously treated cases). Multi-drug resistance was 4.9% (1.3%
in new cases, 20.5% in previously treated cases). The resistance pattern in re-
treatment patients was Isoniazid, (33.3%), Streptomycin (31.1%), Rifampicin (20.5%)
and Ethambutol (9.9%).
Compared to the survey of 1998-1999 multi- drug resistance in new cases has
declined from 3.6% to 1.3% (p<0.01), any form of resistance from 13.2% to 11.0%
and resistance to all four drugs from 1.8% to 0.8%. In previously treated cases drug
resistance has increased. Multi drug resistance has increased from 12.5% to 20.5%,
any drug resistance has increased from 28.6% to 40.9% (p<0.05). However resistance
to all 4 drugs has decreased from 9.8 % to 9.4%. The reduction in resistance in new
cases is likely to be the result of the successful DOTS programme during the last three
years.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002               Page 15




                                    Anti-TB drug resistance surveys
      Pattern                   1996-1997              1998-1999                                  2001-2002
                           Primary    Acquired   Primary      Acquired                     Primary      Acquired
   Total tested              787                    673          112                          755          171
                                          0
                           (100%)                 (100%)      (100%)                       (100%)        (100%)
                              77                     89           32                           83           70
Any resistance                            0
                           (9.8%)                (13.2%)      (28.6%)                      (11.0%)      (40.9%)
     Mono-                    45                    51           13                           53           22
                                          0
   resistance              (5.7%)                 (7.6%)      (11.6%)                       (7.0%)      (13.0%)
   Multi-drug                 9                     24           14                           10           35
                                          0
   resistance              (1.1%)                 (3.7%)      (12.5%)                      (1.32%)      (20.5%)
  Resistance to                                     12           11                            6           16
                              0           0
   all 4 drugs                                     (1.8)        (9.8)                       (0.8%)       (9.4%)
Table 3: Anti-TB drug resistance surveys in Nepal
Source: NTC

Development of the health policy agenda in Nepal
The policy framework for Nepal’s health sector has undergone significant
developments in the last 10 years. Following restoration of multiparty democracy in
1990, a new National Health Policy was introduced in 1991. This paved the way for
the newly created Department of Health Services under which a strong focus was
the strengthening of primary health services delivered through a network of Primary
Health Care centres (205 – one per electoral constituency), Health Posts (712) and
Sub-health Posts for every Village Development Committee (3138). National
planning is normally undertaken by means of ‘Five Year Development Plans’ which
are published by the National Planning Commission. The 8th (1992-1997) and 9th
(1997-2002) five year health plans focused on this extension of basic services to rural
communities together with a policy of strengthening health service management,
technical supervision, monitoring and evaluation. The 9th plan also identified the
district as the focal point for decentralised planning and management of health care
services.
The production of the Second Long Term Health Plan (SLTHP 1997-2017)
provided the broad framework from which the 20 components of the Essential
Health Care Services (EHCS) package were identified as priority programmes. The
control of infectious diseases including tuberculosis was one of these named priority
elements.
In order to build on the work of the SLTHP, reassess the capacity of the health system
and develop a more coherent approach to planning and development in the health
sector a document entitled a Strategic Analysis to Operationalise the Second Long
Term Health Plan was produced by a consortium of Government Ministries, the
National Planning Commission, the World Bank, External Development Partners
(EDPs) and International Non-Governmental Organisations (INGOs) in early 2000.
Four actions were proposed from this report:
    Strengthening health service delivery
    Decentralisation
    Actions to improve the public-private-NGO mix
    Strengthening sectoral management
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 16


An additional key driver in the analysis of health care resources and policy
development was the preparation and publication of the World Bank Report ‘Nepal,
Operational Issues and Prioritisation of Resources in the Health Sector’, June
2000. This report generated 5 recommendations:
   Increase political commitment
   Focus on Group 1 diseases (which included tuberculosis)
   Develop institutional capacity – by creating a strategic framework and using
   existing resources efficiently and effectively
   Develop better health care systems – by developing public-private partnerships
   Establish priorities – by identifying sequenced priority interventions

Together these two comprehensive reviews highlighted the strategic areas for the
preparation of the Medium Term Strategic Plan (MTSP) which was published by
His Majesty’s Government in February 2001. This document in the form of detailed
logframes laid out the four areas for strategic interventions to be incorporated into the
health sector component of the 10th Five Year Development Plan 2002-2007). The
MTSP was also a tool to provide a basis for the development of a sector-wide
approach and to guide collaboration and investment by development partners and
agencies.

Table 4: Goal and Purposes of Medium Term Strategic Plan
Goal:
   Health status of the Nepalese population improved through a health care system
   that provides equitable access to quality health care
Purposes:
1. An effective health system developed for the provision of affordable and accessible
     EHCS
2. Public-private-NGO partnership in health care provision promoted
3. Effective decentralisation in health system provision ensured with participatory
     approaches at all levels
4. Improved quality of health care provided by public-private-NGO partnership
     through total quality management (TQM) of human, financial and physical
     resources

Following on from this work was the preparation of the Medium Term Expenditure
Programme (MTEP)6 to Operationalise 1st Three Years of 10th Five Year Plan’s
Health Programmes, January 2002. This document also embraced the requirements
of the Interim Poverty Reduction Strategy Paper (I-PRSP) for Nepal. Key
programmes and activities were prioritised into 3 groups. Tuberculosis control was
identified as one of the Priority 1 Programmes based on the parameters of: burden
of disease, implementation capacity, equity consideration, programmes directed to the
poor, marginalized, vulnerable and disadvantaged groups, programmes contributing to
poverty alleviation and availability of resources. The document identified the inability
to clearly determine financial requirements for the health sector and makes a number
of recommendations including:
    The creation of ‘national health accounts’ covering public, private, NGO and
    EDP health sector expenditures at all levels of the health system



6
    This is also sometimes referred to as the Medium Term Expenditure Framework (MTEF)
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002         Page 17


      The establishment of a health economics body7 to provide technical support to the
      Ministry of Health (MoH) on health financing issues.
    Develop a common financial reporting framework for all EDPs. Interestingly the
    document notes that, ‘the process could build on steps already taken to develop
    sub-sector programmes such as TB, leprosy and reproductive health.’
The implications of the MTEP for donor assistance and donor behaviour is discussed
along with the declaration of HMG to identify the 10th Five Year Development Plan
as the Nepal Poverty Reduction Strategy Paper. Finally the document encourages a
move towards a Sector Wide Approach (SWAp) in order to optimise available
resources from EDPs.




7
    The Health Economics & Financing Unit (HEFU) of the Ministry of Health has now been established
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002          Page 18




Millennium Development Goals
HMG/N was a signatory to the Millennium Declaration in September 2001. The first
progress report on the status of attainment of the Millennium Development Goals
(MDGs)8 in Nepal was published in February 2002. These 8 goals and 18 targets aim
to create an environment conductive to development and the elimination of poverty.
The health sector is particularly involved in 5 of these targets. In particular, target 8
sets out 2015 as the year by which the incidence of malaria and tuberculosis should be
halted & reversed. The identification of TB in the National MDGs is highly
significant for the prioritisation of the national TB control effort.

Local Self Governance Act (1999)
This act established a framework for decentralisation to the district level. It would
involve increased responsibilities for health care delivery being devolved to District
Local Development Committees. The full implementation of this Act is scheduled to
take place during the 10th Five Year Development Plan period 2002-2007.

The Health Sector Reform Process in Nepal
In May 1997 a meeting was held in Kathmandu involving HMG and EDPs to consider
a more coherent approach to planning and development within the health sector.
Despite general agreement at that time little follow up action occurred. In 1999
following an assessment of stakeholders to support a government led joint strategic
analysis of the health sector the HMG expressed a clear wish for EDPs to move
towards a sector wide approach in planning and delivering health care.
The initial outcome of this work was the preparation and publication of the Strategic
Analysis to Operationalise the Second Long Term Health Plan in May 2000.
Together with the policy framework contained in the 1991 National Health Policy
and the SLTHP this work progressed into the formulation of the MTSP and MTEP as
route maps for the health component of the 10th Five Year Development Plan (2002-
2007). The reform process is led by a Health Sector Reform Committee and chaired
by the Health Minister. A separate core group comprising the Planning Division, key
officials of the MoH, National Planning Commission, Ministry of Finance, EDPs and
private and health related professional organisations was tasked to produce a coherent
Nepal Health Sector Strategy.
The outcome of this work was the recently approval by the MoH of the Nepal Health
Sector Strategy – An Agenda for Change, June 2002. Currently a Programme
Preparation Team has been formed to prepare a fully costed Nepal Health Sector
Programme – Implementation Plan.
The time frame for donor commitments to this programme implementation plan is
Spring 2003 and operationalisation of the plan in the next Nepal fiscal year beginning
July 2003.




8
 The Millennium Development Goals (MDGs) are a set of goals and targets for monitoring human
development. They are centred around 8 main goals and 18 targets: 1. Eradicate poverty & hunger; 2.
Achieve universal primary education; 3. Promote gender equality and empower women; 4. Reduce
child mortality; 5. Improve maternal health; 6. Combat HIV/AIDS, malaria and other diseases; 7.
Ensure environmental sustainability; 8. Develop a global partnership for development
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 19



The Nepal Health Sector Strategy - An Agenda for Change
The recently published Health Sector Strategy document is the current central guiding
document arising from the sectoral reform discussions in Nepal over the past 3 years.
HMG have set three programme outputs and five sector management outputs which
will be the core of the reform programme over the next 5 years. These are:
Programme Outputs:
   1. EHCS package: The priority elements of an Essential Health Care Service –
      safe motherhood and family planning, child health, control of communicable
      disease, strengthened out patient care – will be costed, allocated the necessary
      resources and implemented. Clear systems will be in place to ensure that the
      poor and vulnerable have priority for access.

     2. Decentralisation: Local bodies will be responsible and capable of managing
        health facilities in a participative, accountable and transparent way with
        effective support from the MoH and its sector partners.

     3. Public-private mix: The role of the private sector and NGOs in the delivery
        of health services will be recognised and developed with participative
        representation at all levels. Clear systems will be in place to ensure
        consumers get access to cost effective high quality services that offer value for
        money.

Sector Management Outputs:
  1. There will be coordinated and consistent Sector Management (planning,
      programming, budgeting, financing and performance management) in place
      within the MoH to support decentralised service delivery with the involvement
      of the NGO and private sectors.

     2. Sustainable development of health financing and resource allocation across the
        whole sector including alternative financing schemes will be in place

     3. A structure and systems will be established and resources allocated within the
        MoH for the effective management of physical assets and procurement and
        distribution of drugs, supplies and equipment.

     4. Clear and effective Human Resource Development policies, planning systems
        and programmes will be in place.

     5. A comprehensive and integrated management information system for the
        whole health sector will be designed and implemented at all levels
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 20



NTP and the current security situation
Over recent years there has been escalating violence between Maoist groups and the
government. Originating in the remote hill districts this violence has extended
throughout the country causing significant disruption to civil life and the delivery of
government services. Unofficial sources would suggest that upward of 70% of the
country is controlled by Maoist forces. Government control backed by security
personnel is confined to Kathmandu, main municipalities, the easily accessible areas
of the terai and the district headquarters in hill and mountain areas. The consequential
political and security environment has major implications for the health sector and TB
control. Key issues are:
    The government has this year revised budget allocations and diverted social sector
    spending to the military and security forces.
    There is increasing anecdotal evidence of accelerated migration from Maoist
    controlled hill areas to urban and peri-urban locations in the major valleys and the
    terai.
    Movement of food and medical supplies within districts has been hampered by
    activities of the Maoists or the security forces.
    Primary Health Care delivery outside of district centres in remote areas has been
    greatly hampered. Staff vacancies have increased and medical supplies depleted.

As the TB control programme is dependant on a functioning PHC system for
diagnosis and treatment in hill areas it is expected that programme outcomes will be
adversely affected. In terai and municipality areas the increased migration will place
additional strain on stretched urban services. Increased poverty and poor nutrition
combined with psychological stresses is likely to increase the breakdown from
infection to TB disease in the population. The potential responses to the situation are
discussed later.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 21



The National Tuberculosis Control Programme
Background
The first organized attempts to control TB in Nepal began in 1934 with the
construction of the Tokha sanatorium. A Central Chest Clinic (CCC) was
established in 1951 to provide curative TB services including free treatment for the
poor. In 1985 the TB Control Project (TBCP) was established and in the same year
Short Course Chemotherapy (SCC) was introduced in some parts of country mainly
by the non-governmental organizations working in TB control.
In 1989, the National TB Programme (NTP) replaced the TBCP and the National
Tuberculosis Centre replaced the Central Chest Clinic. In 1993 SCC was adopted as
the national drug regimen for tuberculosis treatment by the NTP. Following a joint
HMG/WHO review of the NTP in 1994, a 5 year plan based on the WHO framework
for effective TB control, with a policy of Directly Observed Treatment Short course
(DOTS) was prepared, and approved by HMG in August 1995. The joint team
concluded that only 30% of infectious cases at that time were being registered in the
NTP, and only 40% of these cases completed treatment.
The government identified TB as one of its top ten priorities in the 8th and 9th year
health plans. DOTS was introduced into four demonstration centers in April 1996 and
expanded throughout the country in the following 5 years. By July 2001, DOTS was
being delivered through 227 treatment centres with 684 sub-centres and covered 84%
of the population, across all 75 districts.


NTP Objectives
  85% cure rate in new smear-positive pulmonary tuberculosis cases
  70% case detection ratio in new smear-positive pulmonary tuberculosis cases
  Directly Observed Treatment, Short Course (DOTS) available in all 75 districts of
  the country through the NTP
  By the end of the Tenth Fiscal Year Plan all the patients should be treated under
  DOTS strategy


NTP Strategies
  Gradual expansion of DOTS throughout the country
  Establish a treatment centre with microscopy facilities for every 40,000-
  100,000 population, with sub-centres as required.
  Promote early detection of infectious pulmonary cases on the basis of
  sputum smear examination.


Major NTP Policies
  The basic unit of the NTP for diagnosis and treatment is the district
  hospital and primary health care centre.
  All centres offering TB treatment must utilise the standardised regimens of
  short course chemotherapy (SCC) adopted by the NTP, with Directly
  Observed Treatment, Short Course (DOTS).
  Free anti-tuberculosis treatment to all patients with active tuberculosis,
  through the basic health services, with a priority for sputum smear-positive
  cases, in every district of the country
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 22


     Evaluation by four monthly cohort analysis of treatment outcome
     Community involvement for DOTS implementation


NTP Activities
  Establish a national network of microscopy centres, and a system for
  ensuring quality of sputum smear examination
  Organise treatment delivery and supervision of programme activities
  through the general health services of the country, in an integrated way
  Ensure continuous drug supply and monitor the quality of drugs.
  Maintain a standard system of recording and reporting in line with the
  integrated Health Management Information System of the department of
  health services
  Monitor the results of treatment and evaluate progress of the programme
  by means of 4-monthly cohort analysis
  Develop and maintain the skills of health workers by providing training.
  Promote involvement of the community in the NTP.
  Strengthen co-operation between NGOs and development partners
  involved in the NTP
  Co-ordinate NTP activities with other PHC activities carried out in the
  country, especially leprosy and AIDS/STD programmes
  Conduct relevant research to improve the effectiveness of the NTP.


NTP Organisation
At the national level the National Tuberculosis Center is the central unit of the NTP.
The Director of the NTC manages the National Tuberculosis Centre and National
Tuberculosis Programme. NTC staff provide technical support to the field programme
as well as running the NTC referral clinic and laboratory. The Regional Tuberculosis
Centre (RTC) in Pokhara provides a focus for technical support in the Western
Region.

At the regional level, all activities are carried out with the co-operation of the 5
Regional Health Services Directorates. Regional tuberculosis/leprosy assistants
(RTLA) support the Regional Health Services Directorate in managing TB control
activities in the region.

At the district level, the district health officer (DHO) is responsible to plan and
implement NTP activities. A district tuberculosis/leprosy assistant (DTLA) supports
the DHO in the management of TB control activities. Within the district, the basic
unit for diagnosis and treatment of patients with tuberculosis is the district hospital
and the primary health centre. Diagnostic and treatment services will not usually be
provided lower than this level, though health posts may act as sub-centres for
supervision of patients on DOTS.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                             Page 23



               Organisational Chart of the NTP
  Responsibilities
                                                     Ministry of Health

 Co-ordination of the NTP                            Director General
 within the health services                          of Health Services
 Technical policies for the NTP
 Planning, Monitoring and Evaluation                  National Tuberculosis Programme/
 Training, Supervision and Research                  National Tuberculosis Centre, Director           Other National
                                                                                                        Centres &
 Management of the NTP at the                                                                        Divisions of DOH
 Regional Level                        Regional Directors
                                                                                                    NCASC PFAD
 Training and Supervision                                                                           NPHL     EDCD
 Monitoring
                                                                 RTC/RTLA
                                                                                                    NHTC     LMD
 Management of the NTP at the         District Health                                DOTS           NHEICC HRDD
 District Level                          Officers                                   committee       AIDS Centre
                                                                DTLA                                CHD      FHD
 Diagnosis, tratment and
 Monitoring                      Primary Health Centres
                                                                         NGOs              KEY
 Case Holding and                      Health post                                         Main Structure of NTP
 Treatment                                                                                               Line Management
                                                                                                         Technical Supervision
 Case Holding / Tracing            Sub Health Posts               Communities



Logistics
NTC is responsible for national estimates and procurement of anti-tuberculosis drugs.
The central store of anti-tuberculosis drugs is located in the NTC. Drugs are
distributed from the NTC with support of the Logistics and Management Division
(LMD). At the regional level supporting INGOs (Eastern, Central, Mid Western and
Far Western Regions) and RTC (Western Region) manage drug supply from the
central store up to the district with close cooperation of LMD and the Regional
Medical Stores (RMS). Logistic below the district is managed by the respective DHO
(with assistance from the supporting INGOs if required).
Agencies supporting the NTP
Bilateral and multi-lateral agencies, INGOs, NGOs and research institutions together
provide substantial support with financial assistance, technical assistance, materials in
kind, diagnostic and treatment services, research and management capacity.
Norwegian Aid (NORAD) has been supplying anti tuberculosis drugs to the NTP for
the last two years. The Norwegian Heart and Lung Association (LHL) has
supported the NTP through the provision of funds for supervision, training, research,
supply of anti- tuberculosis drugs and the NTP annual review programme.
The Department for International Development (DfID), UK, is currently providing
anti-TB drugs and manpower support channelled through WHO for a five year period.
The Japan International Co-operation Agency (JICA) supported the construction
of the NTC and RTC buildings in Thimi and Pokhara, TB activities in the Western
region, the supply of anti-tuberculosis drugs, logistic management system
development and technical support at the national level. JICA has also contributed to
the development of the TB microscopy and quality control network. Currently JICA
are supporting an urban TB control programme through their Community TB and
Lung Health Project (CTLHP) in Kathmandu and Rupandehi.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 24


The World Health Organisation (WHO) supports the NTP through the provision of
staff and funding for training courses, attendance at international conferences and
research into multi-drug resistance & HIV-TB.
The International Union Against TB and Lung Disease (IUATLD) provides
technical support and consultancy to the national programme.
The SAARC Tuberculosis Centre (STC) is physically located within the NTC
building and has organized several regional training courses in Nepal over the last
five years.
The Britain Nepal Medical Trust (BNMT) supports TB services in the Eastern
region through training, supervision and drug logistics.
The International Nepal Fellowship's Tuberculosis Leprosy Programme (INF
TLP) supports government tuberculosis services in the Mid-West region through
training, supervision, laboratory quality control, and logistic supply. In addition, TLP
runs four referral clinics in Nepalgunj, Ghorahi, Surkhet and Jumla.
The Netherlands Leprosy Relief Association operates in the Far West region
supporting the NTP through drug supply, laboratory quality control, training and
supervision.
The United Mission to Nepal (UMN) provides TB services in all of its general
hospitals including the Tansen hospital which is one of the largest TB diagnostic
centres in the country. In addition, UMN has provided support to HIV-related
counselling for TB patients.
The German Nepal TB Project (GENETUP) is supporting TB control activities in
Kathmandu, Bara, Parsa, Rautahat, Sarlahi and Mahottari.
The Nuffield Institute for Health, UK, is involved in technical support for research
into the adaptation of DOTS to suit the mountainous areas of Nepal and also into
building links between the private sector and the NTP.
The Nepal Anti-TB Association (NATA) plays an important role in controlling TB.
It has health education activities at district level, and also provides treatment services
in 7 districts.
Quality control system for sputum smear microscopy
A quality control (QC) system for sputum smear microscopy was implemented in
Nepal in 1996 coinciding with the start of DOTS implementation. Currently there are
5 Regional Quality Control Centres with trained quality control assessors (QCA) who
carry out quality control on a quarterly basis.
Research
Two international collaborating centres support TB related research projects in Nepal.
These are the Nuffield Institute of Health (UK) and the Research Institute of TB
(RIT) in Tokyo, Japan. Current research includes:
   Family based DOTS and Community based DOTS. A Randomised Controlled
   Trial (RCT) to identify appropriate tuberculosis treatment delivery strategy in
   hard to access areas (10 hill districts) of Nepal, where institution based DOTS is
   not feasible to all TB patients.
   Pilot research to link private practitioners and NGOs with the NTP, to ensure that
   all patients receive a high standard of care and their results are reported.
   Drug resistant surveillance survey with participating sites across the country.
   The provision of voluntary HIV testing is being piloted in 5 major diagnostic TB
   centres.
   An Adult Lung Health Initiative international study to develop guidelines for the
   management of respiratory symptomatics attending primary health care facilities
   is underway in 2 districts.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002           Page 25




Lessons for the Nepal Health Sector
What lessons can be drawn both positive and negative from the experiences of the TB
control programme in Nepal? In the eyes of many it has been a success story but what
are the learning points for other programmes and the future development of the health
sector? This section looks to provide insights of value to non-TB programmes while
the later section ‘Lessons for the Region’ seeks to highlight issues for other TB
programmes in the region. Technical aspects of TB control are therefore addressed in
the later section while this section concentrates on generic issues of programme
management, organisational culture and implementation. The section concludes
by considering the implications of health sector reform (HSR) on the TB programme,
and asks how the TB programme might assist or hinder the current reform process in
Nepal.

Leadership
A consistent theme which arose in interviews was the impact of the NTC Director’s
leadership of the programme as a key success factor. He has clearly earned the respect
of his staff and they are motivated by his action-oriented leadership style. The NTP
has been fortunate to have had a number of motivational senior staff associated with it
who have all contributed to the leadership success of the programme. The lesson is
that leadership is vital for success and should consist of:
    Consistency – the value of retaining a good director in the same programme for a
    prolonged period of time
    Quality – good leaders should be identified and equipped with the necessary
    technical and managerial training for their task.9
    Reach – to gain respect of staff and a clear understanding of the programme the
    leader must be prepared to make many field trips.
    Delegated responsibility – within the NTC tasks have been clearly defined and
    delegated. This reduced the inefficiencies often seen in health programmes when
    all decisions are referred up to the director.
    Example – Dr Bam and his senior officers work hard and long hours and demand
    the same of their staff. Demonstrating a positive work ethic can diffuse throughout
    the programme.

Strong team approach
Under-girding the leadership was a strong, motivated and technically capable team
consisting of the NTC staff, the regional and district level supervisors, the officers of
the various implementing INGOs and significantly, the Nepal WHO TB Medical
Officer. It should be emphasised that it was the particular synergy of the central level
team at NTC, the WHO medical officer and the NTP Director that together provided
the impetus and direction for the programme in the mid to late 90s.

Staff motivation
At central and district level there was a general impression that staff enjoyed their
work and were able to make a difference. Empowered staff are a powerful driver for
success and innovative implementation. Evidence of commitment and enthusiasm for
DOTS was also described at the local health post level. The key issues identified
were:

9
 In Dr Bam’s case he benefited from training in TB control and epidemiology at the Research Institute
of Tuberculosis in Japan.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 26


     Staff saw the DOTS approach produce results which re-enforced job satisfaction
     Staff were trained, equipped and motivated
     The JICA RIT training programme has provided excellent technical and
     programme management training for successive cohorts of TB staff.
     The LHL funding has emphasised the requirements of quality technical training
     and supervision at all levels.
     Peer-led monitoring and evaluation – this is discussed below.
     The national & international recognition of the Nepal TB programme through
     the honouring of Dr Bam with various awards brought a significant moral boost
     to all staff working for the programme.

Communication
Compared with other programmes the NTP displays a culture of wide and open
communication. This communication is:
   Upward communication – in the form of advocacy, and awareness-raising to
   senior government staff, politicians and the international TB donor community.
   Outward communication – in the form of widespread proactive media
   reporting, health education activity to communities, and a wide range of tailored
   training programmes for health care workers and social action groups.
   Inward communication – across all cadres of health care staff working in TB
   control. This has created a shared vision and clarity of purpose using the DOTS
   strategy.

Peer review
Closely linked to communication and staff motivation is the regularised practise of
‘peer based review’ for staff working in TB control. This quality improvement
process can be seen throughout the programme:
   International – by means of the IUATLD technical consultancy field visits
   funded by LHL and the annual national review process. By ensuring one external
   expert joins each regional field team the local managers are exposed to
   international technical expertise in programme evaluation.
   Regional (Asia)- The development of the annual South-East Asia Regional NTP
   Managers Meeting provided a platform for national NTP managers to be held
   accountable to their peers in the Region. Nepal as host country for the meetings
   benefited from the extra pressure of having its programme ‘on show’ and being
   able to include more NTP staff as observers or participants.
   National – by means of the trimesterly meeting of the Regional TB/Leprosy
   Assistants to review the last trimester’s data and plan for the future. In addition,
   most years there have been large national TB seminars held at NTC which have
   afforded District Health Officers the opportunity to meet and discuss their local
   TB control efforts.
   Regional, district, and treatment centre trimesterly reviews – at each level of
   responsibility the programme has instituted review meetings to generate and
   analyse the cohort report for the last trimester and be accountable for local
   programme performance. This greatly increases ownership of data, problems and
   ultimately local solutions. Indeed the emphasis of these meetings is identify and
   solve problems locally.

Sharing of best practice
The quarterly cohort reporting schedule and associated technical peer review
meetings are the vehicle through which district, regional and national planning is
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 27


discussed and shared. However staff interviewed also highlighted the value of other
means of sharing best practice across the programme:
    Observational visits – permit staff to visit ‘model DOTS’ programmes in other
    areas to share their own experiences and pick up new approaches that may be
    introduced in their own treatment centres.
    SAARC, IUATLD and WHO seminars and training events – The Nepal
    programme has been most fortunate to regularly host international training
    programmes and as a result national staff have benefited from the opportunity to
    attend and learn from TB technical staff working across SE Asia.

Central policy – local innovation
The NTP is a good example of a technical programme which operates according to a
clear national policy yet encourages local application of the model. The key features
of this success factor are:
    Central features
         o National adoption of an evidence-based strategy (DOTS Strategy)
         o Documentation of a policy framework and national implementation
            manual (NTP manual) in Nepali as well as English language
         o Training materials in Nepali prepared for each cadre of staff
         o Strong emphasis on recording and reporting of programme outcomes
    Local innovation - a number of witnessed examples are listed to demonstrate the
    diversity of initiatives taken to apply the basic tenets of the DOTS strategy:
         o A private nursing home in Lalitpur (Hargans Nursing Home) decided to
            provide a daily rice meal to several homeless patients with TB to
            encourage their regular attendance for directly-observed outpatient
            treatment of their TB.
         o The UMN Yala Urban Health Programme (YUHP) has developed links
            that permit access to local carpet factories to seek out workers with TB.
            The programme has also trained ward/tole level volunteers who will carry
            sick patients to the clinic daily.
         o The INGOs are encouraged to develop local strategies to meet local needs
            such as the INF ‘default tracers’ attached to the Nepalganj Clinic.
         o BNMT has provided 'hostel facilities' at a district centre to those who are
            unable to attend the DOTS clinic on a daily basis in a hill district of
            eastern Nepal (Dhankuta).

High quality technical support
A theme raised by interviewees as a reason for the particular success of the
programme was the consistent high quality technical assistance available to the NTP
over the previous decade. Of note were both the quality of the technical assistance
and the generally positive nature of relationships between the NTP and technical
assisting agencies. This particular feature of the NTP is multifaceted and has been
additive through the 1990s. Indeed certain reviewers went as far as to suggest that the
INGOs contribution has been the backbone of the TB control programme in Nepal.
The chronological development was as follows:
    Central assistance from JICA and JAT technical assistance to NTC and RTC
    District and regional assistance from technically focused INGOs such as
    GENETUP, INF, UMN, BNMT and NLR.
    The TB related NGO collaboration which later became formalised as the TB
    Control Network (TBCN)
    The quality of the initial WHO review process in 1994
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002          Page 28


       The recruitment of Ian Smith as the first WHO TB Medical Officer who not only
       drafted the initial plan but also was integral to the implementation of the first 5
       year development plan
       The impact of the annual external technical reviews
       The development of the annual TBnet conferences hosted by NTC
       The increasing impact of the SAARC TB Centre
       Nepal as host to the WHO/IUATLD Asia TB Programme Managers’ Training


Focused and consistent external donors
The funding of the NTP resource envelope is discussed in greater depth later in the
report but the key success features are:
   The continuity of the donor partners
   The in-country presence of many of the donor agencies
   The opportunity for donors to meet annually at the Technical Advisory Group
   (TAG) meetings

Partnership working
The past 5 years have witnessed major expansion of partnership working to deliver
the DOTS strategy across health institutions and civil society. Now DOTS is
administered through partnerships with:
    Academic institutions and private medical colleges
    Tertiary, regional and NGO operated hospitals
    INGO regional counterparts
    Private nursing homes
    NGOs such as NATA
    DOTS committees formed at the treatment facility level.10
    CBOs such as womens groups responsible for a DOTS treatment centre
    The media – although not actually acting as a delivery point for DOT are a major
    partner in the awareness raising component of the NTP strategy.

Appropriate and phased decentralisation
Decentralisation is a significant platform of the HSR process and therefore it is
interesting to review the NTP from this perspective. Some commentators felt that the
NTP has not been particularly active in the decentralisation process however we
would disagree and point to the following positive developments in this area:
    The creation of the DTLA posts in every district was a major pillar in the
    decentralisation of supervision and associated district level NTP functions within
    the District Health Office.
    There is evidence that the decentralisation of functions has been measured and
    responsive to the strength or weakness of the supporting technical or managerial
    structure. Thus logistics management was only partially decentralised to the
    regional INGOs as drug supply was seen as critical to the success of DOT. More
    recently however active plans have been made to pass responsibility to Regional
    Medical Stores and provide the required technical support to maintain an
    uninterrupted supply chain.
    With the recruitment of RTLAs and DTLAs into government service the
    implementing INGOs were able to provide counterpart staff to work alongside the


10
     Members from these committees are now participating in VDC health co-ordination committees
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002            Page 29


       DTLAs in the District Health Offices. This enabled the fast transfer of knowledge,
       skills and attitudes in TB control from the INGO staff to the government staff.

The formation of action – orientated, structured networks
As a natural outworking of the above organisational culture of communication, peer
support and partnership working, networks emerged which grew through the mid-
1990s to become significant models for public health at a Regional and national level.
Three examples of these are:
   TBCN – the TB Control Network. This arose from a desire by the in-country
   implementing INGOs, the leader of the JICA JAT, and NATA to agree on case
   definitions, reporting mechanisms and shared health promotion activities. This
   expanded into a national group with documented group values, procedures and
   functions. The meetings were soon hosted at NTC and attracted a widespread
   commitment from agencies involved in the delivery of TB services across the
   country. When the development plan was launched in late 1994 this group had
   already worked through the ‘forming, storming, norming’ stages of group
   development and reached a high level of ‘performing’11. It provided the NTP with
   the ideal platform for the required change management process necessary to
   implement all the enhanced features embedded in the TB development plan.
   Interestingly the TBCN became a model for a similar group set up by the
   counterpart INGOs working in the Leprosy field in Nepal.
   TBNet – in many ways TB-net grew from the principles of the TBCN. TBNet
   originated from a meeting sponsored by the TEAR Fund UK evaluation unit to
   bring together NGOs that it supported throughout the south-asia region in 1992.
   The purpose was to identify model programmes and generate a guidance
   document. The experience of sharing ideas, supporting one another and making
   contacts across the region was so stimulating that the principle of a annual
   meeting, hosted in Kathmandu grew to become a much larger staged event and
   attracted global attention for its impact on TB action. The focus was on
   strengthening the capacity of the NGOs working in TB control and to be an
   independent, informal participative network using email, a website, published
   documents and an annual 2 day TBNet Conference as the means of shared
   communication. The steering committee was mostly composed of TB related
   professionals working in Nepal and so Nepal became the natural locus of TB
   information, training and activity. TBNet was probably one of the factors that
   brought the annual WHO/IUATLD TB programme managers training to Nepal.
   TBNet has now been absorbed into the STOP TB Partnership and many of the
   principles of the original group can now be seen in the workings of STOP TB at a
   global level.
   DOTS committees – while TBNet was a network that quickly expanded its
   impact outwards across the Region, the introduction of local DOTS committees is
   an example of the same principles applied at the grass roots of treatment delivery.
   These committees are formed, trained and sparked with enthusiasm to act as a
   local community based accountability mechanism for DOTS treatment centres.
   Membership seeks to cross the public, political, NGO and CBO spectrum of the
   locality. While not all are equally active there are some pathfinder examples of
   well functioning DOTS Committees.




11
     See ‘On the Workings of Groups’ in Handy, Understanding Organisations, 4th Edn 1993, Penguin
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002       Page 30


Summary of key ‘success factors’
The matrix below seeks to summarise the success factors identified in the operation of
the Nepal TB programme. The allocation of the tick marks is highly subjective and
various combinations could be constructed. However the key message is that three
skill areas are required – interpersonal, technical and administrative. We believed
that the most critical skill is that of interpersonal communication and that technical
and administrative capacity are required in equal measure for the successful
implementation of a programme.

                                                               Skill areas required
    Success Factors
                                       Interpersonal               Technical      Administrative
1. Leadership
2. Strong team approach
3. Staff motivation
4. Communication
5. Peer review
6. Sharing of best
practice
7. Strong central policy
    with local innovation
8. Quality technical
support
9. Focused and
    consistent external
    donors
10. Partnership working
11. Appropriate & phased
    decentralisation
12. Action-oriented
    structured networks
Table 5: Success factors and skill areas



                                             Interpersonal skills




                                                    Success
Negative factors
Not all those interviewed were convinced of the ‘success’ of the Nepal TB
                                                      Administrative skills
programme.Technical skills or alternative perspectives were raised. These are
             Issues of concern
discussed below:
    “Successful but not a model” – it was suggested to the author that TB control as
    a public health programme is technically straightforward to implement – narrow
    case definition, evidence-based treatment protocols, delivered through primary
    care setting. And when combined with the fortuitous state of charismatic and
    consistent leadership, high quality external technical assistance and a solid
    external donor support base much more should have been delivered by the
    programme than is apparent.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 31


     “Immature and dependent” – despite the consistent external assistance in terms
     of finance, technical expertise and in – country implementing INGOs the central
     unit of the NTP based in NTC remains managerially vulnerable in terms of
     programme planning and administration.
     “Not sufficient acknowledgement of areas of weakness” – the apparent success
     of the pro-media approach to advocacy has overshot and now the programme has
     difficulty in acknowledging areas of weakness. One recent example of a technical
     area of concern would be the ongoing case finding gender imbalance.
     “Not enough emphasis on urban TB services” – in response to the current
     security climate there has begun a rural population migration towards the relative
     security of urban areas. The need therefore to strengthen TB services for already
     pressed urban facilities is urgent. While the JICA CTLHP has moved to support
     selected urban DOTS in the Kathmandu area the NTP as a whole continues to
     focus resources on service coverage for remote districts.
     “Strong elements of vertical programming remain” – despite full integration at
     treatment facility level the NTP continues to operate essentially vertical, and
     separate mechanisms for delivery of TB training, logistics supply, supervision,
     and programme statistical reporting. Some saw this as one of the NTPs greatest
     strengths while others saw this as a negative feature.

New areas for attention
We asked those interviewed about the challenges that face the NTP in the future.
While some issues relating to the interaction between the NTP and HSR are addressed
later in this section other issues are a direct current challenge:
    The impact of the Adult Lung Health Initiative – this symptom-based approach
    to lung health is conceptually attractive and already both the JICA project and the
    WHO in Nepal have embraced the approach. For a single disease-based
    programme to broaden its scope to encompass both the preventive public health
    approach and the need for a patient focussed clinical service is a major challenge.
    The impending tobacco-related disease epidemic – as the cohorts of heavy male
    and female smokers mature there will be a major increase in lung cancer and other
    forms of lung disease. A strategic approach is required to reduce smoking habits
    in Nepal and cope with the impending burden of lung pathology. While this is a
    decision required of the Ministry of Health perhaps the NTP is best positioned to
    lead an integrated public health response to tackle this problem.
    HIV/TB linkage – There has been little evidence of truly joint planning and
    implementation of activities between the National AIDS Centre and the National
    TB Centre. Anecdotally this is due to elements of ‘protectionism’ within both
    camps to keep the donor monies attached to either programme separate. As the
    AIDS epidemic swells across Asia and the requirement for treatment and care as
    well as prevention emerges as a significant component of HIV management the
    inter-working of the HIV and TB programmes becomes a greater necessity for
    Nepal.
    Integration maturation – as identified above the NTP is on a continuum between
    wholly vertical control and decentralised integration of a number of component
    TB control activities. The direction of travel is most definitely towards greater
    degrees of decentralisation and integration with other health departments. The
    distance of travel achieved towards appropriate integration varies according to the
    component elements of the programme. The NTP must identify solutions that will
    retain the ‘DOTS pillars’ and safeguard acceptable programme outputs while
    maximising the policy of interdepartmental working and the provision of
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002            Page 32


     integrated logistics, training, supervision and reporting systems in the health
     sector.

The Impact of Health Sector Reform
Background
The shape of Health Sector Reform (HSR) varies from country to country and hence
definitions vary. One generic description is that HSR is concerned with ‘defining
priorities, refining policies, and reforming the institutions through which these
policies are implemented.’12 A fuller definition is given by Cassels who describes
HSR as ‘ a sustained process of fundamental change in policy and institutional
arrangements guided by the government, designed to improve the functioning and
performance of the health sector and ultimately the health status of the populations.’
13
   Weil14 summarises the over-arching objectives of reform as:
    Improved efficiency
    Improved equity
    Improved quality
She goes on to identify 9 themes or strategies seen in HSR processes across the world:
    Decentralisation
    Programme integration
    User fees in public facilities
    Focussed provision of essential services packages
    Sector-wide approaches (SWAps)
    Civil service reform
    Corporatisation of public hospitals
    Engaging the private sector
    Expanding insurance cover

The impact of HSR on national TB programmes has been a topic of debate and
research since the late 1990s. Stimulated by a workshop organised by the
International Union Against TB and Lung Disease (IUATLD) and the International
Development Research Centre (IDRC) in Paris is December 199715 an edition of the
International Journal of Tuberculosis and Lung Disease16 in July 2000 was devoted to
a review and various national case studies. In the two opening editorials17 18 of that
edition of the journal seven statements of advice were offered to readers:
    Advocacy at the highest level to secure or maintain political commitment.
    Proactive participation in the reform process by being present ‘at the table’
    during the planning stages. Ensure that core elements of the DOTS strategy such
    as uninterrupted drug supplies are ring fenced during periods of rapid reform.



12
   Cassels A. Health sector reform: key issues in less developed countries. WHO/SHS/NHP/95.4
Geneva: World Health Organisation, 1995
13
   Cassels A. Health sector reform: key issues in less developed countries. J Int Devel 1995;7:329-374
14
   Weil D.E.C. Advancing tuberculosis control within reforming health systems. Int J Tuberc Lung Dis
2000; 4(7): 597-605
15
   IUATLD/IDRC Workshop. The significance of health sector reform for lung health services. Int J
Tuberc Lung Dis1998;2:1044-1045
16
   Int J Tuberc Lung Dis 4(7), July 2000
17
   Miller B. Health sector reform: scourge or salvation for TB control in developing countries? Int J
Tuberc Lung Dis 2000; 4(7): 593-594
18
   Baris E. Tuberculosis in times of health sector reform. Int J Tuberc Lung Dis 2000; 4(7): 595-596
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 33


     Integration of service delivery but not necessarily of the supportive structures of
     NTPs (such as drug supply, laboratory network, information system) until ‘the
     dust has settled’.
     ‘Education’ of TB focussed donors to secure continuity of their funding within a
     sector wide approach.
     Respond to reforms taking place and learn the new skills required to integrate
     and decentralise such as new training programmes and streamlined supervisory
     methods.
     Document the nature of the reform process on the impact of TB control efforts
     and use TB programme outcomes as an indicator measure of the success or
     otherwise of the reform process.
     Operational research and pilot testing of the effectiveness of various
     institutional arrangements before nation-wide implementation.

Health Sector Reform in Nepal
How could the NTP contribute to the plans for health sector programming in Nepal?
Will the NTP prove to be a lead change agent or a stubborn outsider to the process?
Conversely, how will the reform process impact on the effectiveness of the NTP? As
has been mentioned already the HSR process comes in many shapes and sizes and is
implemented at differing degrees of pace according to the unique national situation to
which it is applied. In Nepal the structural policy framework for the HSR process has
already been agreed and has been described in an earlier section. In summary there
are 3 identified programme outputs and 5 sectoral management outputs. Using these
8 elements as a template this section seeks to identify the positive and negative impact
that the NTP will exert upon the HSR process and vice versa. A table summarising the
elements and the expected impacts follows the more detailed discussions below.
Programme Output Statements:
1. “EHCS package: The priority elements of an Essential Health Care Service – safe
motherhood and family planning, child health, control of communicable disease,
strengthened out patient care – will be costed, allocated the necessary resources and
implemented. Clear systems will be in place to ensure that the poor and vulnerable
have priority for access.”
Impact of HSR on NTP: Highly positive. As TB control clearly lies within the
‘control of communicable disease’ priority element it should therefore be prioritised
for funding and technical resourcing. This support should extend to the requirements
for the anti-TB drug supply. Additionally the ‘strengthened outpatient care’ element is
positive for TB control in that the delivery of the TB service is achieved through the
PHC system and the outpatient departments of hospitals at all levels. The reference to
‘costing’ will drive forward the pressing need for the NTP to consolidate its budgeting
process and more clearly delineate the true financial and other resource inputs
necessary to operate the service. Finally the focus on providing ‘access to the poor
and vulnerable’ will strengthen the hand of TB care as the disease preferentially
impacts the socio-economically disadvantaged.
Impact of NTP on HSR: Positive. The NTP is a good model from the perspective of
an evidence-based technical programme for a disease which targets the
disenfranchised and is implemented through generic outpatient services. As an
established programme with a robust programme monitoring framework it could be
used to pilot the envisaged HSR changes prior to sector –wide roll out of the HSR
policies.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 34


2. “Decentralisation: Local bodies will be responsible and capable of managing
health facilities in a participative, accountable and transparent way with effective
support from the MoH and its sector partners.”
Impact of HSR on NTP: Dependant on quality and pace of the decentralisation
process. The output statement refers to transferring local management to local bodies
for local health facilities. If successfully achieved, local ownership of health facilities
management will benefit programmes such as the NTP that reach the population
through the network of health posts and sub-health posts. However previous
experiences of ‘decentralisation’ within the health sector in Nepal has been of a
‘decentralisation by decree’ approach which was not supported by national or local
change management arrangements. Robust transitional arrangements will be required
to ensure there is no interruption to the delivery of services during this phased
movement of responsibility from the centre to the district.
Impact of NTP on HSR: Potentially positive. The longstanding experience of the
district and regional level NGOs and INGOs within the NTP is one of close
involvement with service delivery points such as district hospitals, health posts and
sub-health posts. In many situations the support offered by the INGOs has been
focussed to TB or Leprosy however the more efficient approach would be to harness
the ‘onsite’ potential of the INGO or NGO to the decentralisation process and
establish a health post support programme partnership between the Government
District Health Office and the non-governmental sector – be that ‘private for profit’ or
‘voluntary sector’. In this way the expertise of the local partnerships build up by the
NTP could be engaged to more wholistically strengthen and facilitate PHC delivery.

3. “Public-private mix: The role of the private sector and NGOs in the delivery of
health services will be recognised and developed with participative representation at
all levels. Clear systems will be in place to ensure consumers get access to cost
effective high quality services that offer value for money.”
Impact of HSR on NTP: Positive. This HSR driver for change can only be mutually
positive. The international and Nepal approach to the application of the DOTS
strategy is to build stakeholder coalitions and in particular to harness the potential of
the mushrooming private sector. This approach is essential to the NTPs of the South
Asia region where poor quality TB control within private practice can act as the
conduit for the development and spread of MDRTB. ‘Recognition’ and ‘appreciation’
are the key words pertinent to partnership working arrangements with the
CBO/NGO/INGO community. ‘Regulation’ is also required to set clear frameworks
for working arrangements and this is particularly important to the quality standards of
TB control in the private for profit sector. An extension of this ‘regulation’ theme is
for the government to control the quality, formulation and availability of anti-TB
drugs to the private sector.
Impact of NTP on HSR: Positive. The NTP has much experience of partnership
working with the non-statutory sector at strategic, regional, district and community
levels. As a government programme it has developed over time an effective
participative involvement of (I)NGO partners in planning and executing control
measures including quality control mechanisms such as for microscopy services.
Developing effective interaction with the private-for-profit sector has been slow but
progress has been made and valuable experience gained that will be of value to other
programmes.
Sector Management Output Statements:
4. “There will be coordinated and consistent Sector Management (planning,
programming, budgeting, financing and performance management) in place within
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002               Page 35


the MoH to support decentralised service delivery with the involvement of the NGO
and private sectors.”
Impact of HSR on NTP: Uncertain. Without an understanding of the nature and
locus of this statement it is hard to predict impact. The strengthening of management
capacity within the MoH can only be positive for all programmes. Similarly a change
in focus to empower local level service delivery is good news for all programmes
which deliver their functions through integrated PHC facilities. However the
management function should not be divorced from the technical programme expertise.
The transition phase in developing the structures for ‘co-ordinated and consistent
sector management’ could lead to a period of uncertainty which would require careful
change management and extra resources.
Impact of NTP on HSR: Uncertain. The NTP model of trimesterly planning and
statistical reporting meetings held at district, region and centre could be a valuable
vehicle for a phased decentralisation process. Certain functions of the NTP such as
anti-TB drug purchase should not be decentralised as this would lead to dis-
economies of scale.

5. “Sustainable development of health financing and resource allocation across the
whole sector including alternative financing schemes will be in place.”
Impact of HSR on NTP: Uncertain. This statement holds concern for the NTP based
on the experiences of other NTPs undergoing HSR. Too often HSR has led to budget
cuts in an NTP despite the rhetoric of priority funding.19 There is general agreement
that cost-sharing schemes in the public sector for diagnosis or treatment of TB do
form a barrier to access for the poor. As such they are not favoured as a component of
the DOTS strategy. Due to the considerable externalities in the form of ‘public good’
in the reduction of the transmission of TB in the community and concerns over cost
barriers the gold standard for publicly-sponsored TB control is for free diagnosis and
treatment for all. The desire to secure firm funding arrangements for the health sector
as a whole and resource allocation according to sectoral priorities is a positive feature
of the HSR as TB would appear high on the list of priority areas for funding.

Impact of NTP on HSR: Uncertain. It is expected that the current donors of the
NTP would either support the HSR principles or seek to allocate their contribution to
a ring-fenced area of the health sector budget linked to the NTP. There are positive
lessons in the manner in which the NTP has brought donor partners together at the
annual Technical Advisory Group meetings.

6. “A structure and systems will be established and resources allocated within the
MoH for the effective management of physical assets and procurement and
distribution of drugs, supplies and equipment.”
Impact of HSR on NTP: Uncertain. In principle, removing the ‘supporting services’
such as drug procurement, and logistics distribution from previous vertically
organised programmes and incorporating these separate systems into one co-ordinated
expert service is an efficient organisational shift. The experience however in other
countries undergoing HSR reform is that the loss of control of such a critical
programme component as drug supply can be disastrous for programme effectiveness.
Both editorials in the IUATLD journal edition which focussed on HSR highlighted
concerns regarding the early ‘integration of supportive services such as drug supply,


19
  Kritski, AL. Health sector reform in Brasil: impact on tuberculosis control. Int J Tuberc Lung Dis
2000; 4(7):622-626
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002               Page 36


laboratory network and programme monitoring information’.20 If such a process is to
occur it should be rolled out in a phase-wise manner and closely monitored.

Impact of NTP on HSR: Negative. It is likely that until the MoH has established a
robust system with quality assurance monitoring the NTP is both unlikely and unwise
to absolve all responsibility for what is one of the key pillars of the DOTS strategy –
‘an uninterrupted system of drug supply of proven quality’. However the NTP has
made tentative but definite progress along the road towards integrating the NTP
logistics supply chain. Until very recently the onus of transportation and
administration of drug supplies to the regions has been delegated to the regional
implementing INGOs with additional assistance for delivery to districts in certain
areas. The impact of this has been that during the state of emergency TB drugs were
reaching the districts when other health supplies were not. The NTP must commit to
the goal of integrating drug supply while protecting the programme from the
damaging risk of stock-outs.

7. “Clear and effective Human Resource Development policies, planning systems and
programmes will be in place.”
Impact of HSR on NTP: Positive. The NTP depends on the availability of
motivated, trained staff working from equipped facilities at region, district and health
post levels. Many posts in remote districts are unfilled and this greatly hampers all
health care delivered through PHC services. Better staffing is good for all. At the
regional level the TB co-ordinators are currently funded by WHO, these posts should
be transferred into government funded positions if the strategic importance of the
DOTS strategy in Nepal is to be supported within the HSR process.

Impact of NTP on HSR: Positive. The NTP has fostered a motivating and
empowering work culture within regional (RTLA and TB co-ordinators) and district
(DTLA) level staff focussed on TB delivery. The methods employed could be applied
more widely to positive effect in the health sector.

8. “A comprehensive and integrated management information system (MIS) for the
whole health sector will be designed and implemented at all levels.”
Impact of HSR on NTP: Negative. TB programmes use an information system with
a multiple purpose: surveillance, management, and evaluation. Case by case
monitoring of treatment outcome is THE key element and is more important than in
many other diseases due to the risk of worsening the epidemiological situation with
poor treatment outcomes. 21 While most management information systems depend on
a form of district level cross-sectional activity reporting the TB control programme is
built around trimesterly cohort reporting. Cohort outcome reporting must be retained
while also providing appropriate information for a district level integrated MIS.22
Extensive negotiations have already taken place in Nepal around this issue and our
understanding is that the NTP has been permitted to retain the DOTS reporting
mechanism. A reversal of this decision in the interest of streamlining data collection
would be severely detrimental to TB control.

Impact of NTP on HSR: Positive and negative. The NTP has developed a working
system for promoting ownership of results by means of the 4 monthly statistical
20
   Baris E. Tuberculosis in times of health sector reform. Int J Tuberc Lung Dis 2000; 4(7): 595-596
21
   IUATLD/IDRC workshop: The significance of health sector reform for lung services. Int J Tuberc
Lung Dis 1998;2:1044-1045
22
   Chaulet P. After health sector reform, whither lung health? Int J Tuberc Lung Dis 1998;2:349-359
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002           Page 37


workshops for DTLAs. This permits problems to be identified early and corrective
action taken. True ownership of programme outcomes by treatment centres is not
commonly seen in Nepal so lessons could be learned from the NTP model. Others
have suggested that TB services are an apt vehicle through which to measure the
impact of the HSR process.23 This is because the long-term care required for the
successful case management of TB patients is a particularly sensitive indicator of the
ability of the health sector to deliver adequate service. And as the current TB
information system is well developed it could provide a robust high level monitoring
mechanism of the impact of HSR in Nepal. On a more negative note the NTP is
unlikely to support any initiatives to dismantle the DOTS reporting mechanism in the
interests of a totally unified process for collection of district level health sector data.




23
  IUATLD/IDRC workshop: The significance of health sector reform for lung services. Int J Tuberc
Lung Dis 1998;2:1044-1045
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                      Page 38




Programme Output
                                         Impact of HSR on NTP                     Impact of NTP on HSR
Statements
1. EHCS package                                  Highly positive                            Positive
2. Decentralisation                        Dependant on quality &
                                                 pace of the                           Potentially positive
                                           decentralisation process
3. Public-private mix                                 Positive                              Positive
Sector Management
                                         Impact of HSR on NTP                     Impact of NTP on HSR
Output Statements
4. Co-ordinated and
consistent sector                                    Uncertain                             Uncertain
management in place
5. Sustainable
development of health
                                                     Uncertain                             Uncertain
financing and resource
allocation
6. Effective management
of physical assets, drugs                            Uncertain                              Negative
supplies & equipment
7. Human resource
                                                      Positive                              Positive
development
8. Integrated
management information                               Negative                          Positive & negative
system
Figure 3: Summary table of expected impacts across NTP / Nepal HSR interface




Summary
We conclude this section by summarising our assessment of the Nepali NTP against
the 7 recommendations given to TB programme managers as mentioned earlier:

1. “Advocacy at the highest level.” This remains a key strength of the programme.
2a. “Proactive participation in the reform process by being present ‘at the table’
during the planning stages.” This has been a major weakness. The TB programme has
been noticeable by its absence from the planning meetings around HSR.
2b. “Ensure that core elements of the DOTS strategy such as uninterrupted drug
supplies are ring fenced during periods of rapid reform.” This remains to be seen.
However as DfID are fully involved in the HSR process and also have a role in the
funding of the TB drug supplies we have less concern over the risk of disruptions
during the reform period.
3. “Integration of service delivery but not necessarily of the supportive structures of
NTPs (such as drug supply, laboratory network, information system) until ‘the dust
has settled’.” The NTP has achieved good integration of service delivery through the
PHC system while retaining a stronger control over these programme components.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 39


How the current approach responds to the new organisational environment will be
the most testing aspect of the HSR process on the delivery of TB control.
4. “Education of TB focussed donors to secure continuity of their funding within a
sector wide approach.” We are confident that the current donor partners of the NTP
will adapt to the requirements of the HSR process. We expect they may request a
degree of ring-fencing for any contributions to a sector wide funding arrangement.
5. “Respond to reforms taking place and learn the new skills required to integrate
and decentralise such as new training programmes and streamlined supervisory
methods.” We are not so confident that the NTP has prepared for the required
changes that lie ahead. This requires considerable advance planning of which there is
no evidence at present.
6. “Document the nature of the reform process on the impact of TB control efforts
and use TB programme outcomes as an indicator measure of the success or otherwise
of the reform process.” The commissioning of this work and the expected HeSo
research study will provide a valuable baseline from which to monitor the impact of
HSR in Nepal. We would recommend that one of the key indicators for auditing the
HSR process is the cohort outcomes of TB control.
7. “Operational research and pilot testing of the effectiveness of various
institutional arrangements before nation-wide implementation.” We saw no evidence
of planning along these lines from the currently available plans. This is a cause of
some concern.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002      Page 40


Financing of NTP – the resource envelope
Introduction:
The ability to secure sufficient funding from year to year is an essential prerequisite
for the success of an NTP. Adequate funding is a measure of many factors such as the
prevailing political support for the programme, the ability of the programme to
present budgeted medium term plans and the attractiveness of the programme to
potential external donor support. The financial management of the NTP is discussed
below focusing on the following issues:

          The ability of the NTP to compile budgeted plans
          The ability of the NTP to secure political support and government funding
          The ability of the NTP to attract external donor support
          The mechanisms by which funds are released for TB control
          The profile of the donor base
          The ability of the NTP to use ‘released funds’
          The prospects for the next 5 years
          The positive and negative implications of the HSR process on sustained
          resourcing of the NTP

NTP Budgeting
Programmes often fail to secure adequate funding though an inability to present
detailed and costed mid-term plans. This has not been the case in Nepal. Indeed it was
the quality of the 1995-1999 NTP Development Plan24 with the inclusion of summary
and detailed unit budgets that provided the solid platform on which to build a
partnership of governmental and donor commitment. In that plan it was estimated that
the cost of the 5-year development programme would be approximately US 9.5
million with a steady increase in annual requirements. (Figure 4)


           NTP Development Budget 1995-1999
     3
2.5
     2
               US $ (millions)
1.5
     1
0.5
     0
          1995          1996          1997           1998          1999

Figure 4: NTP Development Plan Budget 1995-1999
Source: Tuberculosis Control in Nepal 1995 - 1999
A second 5-year budget projection was formulated for the period 1998-2003 with
similarly detailed breakdown of component costs. This document was able to identify
an increase in government funding over the period 1995-1999 and for the first time to
tabulate the various forms of assistance from NGOs and other development partners.
It was estimated that the non-governmental support from such agencies amounted to


24
  Tuberculosis Control in Nepal 1995-1999, A Development Plan for the National Tuberculosis
Programme, HMG/N Ministry of Health and the WHO, Kathmandu, 1995
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002      Page 41


at least US$ 2.5 million per year.25 The expected 5-year budget for the period was
estimated at US$ 13.2 million. In this calculation the government contribution was
also quantified as 20% of the budget in 1998/99 rising to 30% by 2002/03. (Figure 5)


                     NTP Budget 1998 - 2003
 5

 4          US $ (millions)

 3

 2

 1

 0
      1998/1999 1999/2000 2000/2001 2001/2002 2002/2003

Figure 5: NTP Budget 1998-2003
Source: Tuberculosis Control in Nepal 1998 – 2003 Long Term Plan

Securing political support and government funding
While the NTP is to be commended on its ability to formulate budgeted plans such
plans remain hypothetical until ownership of the financial implications are secured.
Political commitment to the NTP is the key factor in attracting both government
funding and the involvement of external donor partners. The success of the NTP in
Nepal over the last 10 years in is in no small part due to the careful attention given to
political lobbying backed up with financial data. In 1993/4 the total government
budget for tuberculosis was 313,000 constituting 1% of the health sector budget. At
that time the ratio of ‘regular’ to ‘development budget’ was 1:5.2 indicating a heavy
dependency on donors.26 By the financial year 1998/99 this had risen to US$ 0.6
million and by 2001/02 was standing at US$ 1.4 million. This figure does not include
the significant contribution in kind made by INGOs, currently estimated in the region
of US $ 1 million.27 The use of health economics data as a driver for allocative and
technical efficiency in Nepal remains at a primitive stage but even simple financial
data can be used effectively to support the requirements of the programme.

Attracting external donor support
Pre-1995 the external donor commitment to the NTP came in the form of technical
project support from JICA. In addition, the various implementing INGOs such as
GENETUP BNMT, INF and UMN were providing TB services including the
purchase of drug supplies. Post 1995 saw the increased involvement of WHO as a
technical partner, and the offer of direct assistance by LHL who had taken the
strategic decision to cease funding BNMT’s TB activities in the East and provide
focussed financial support for core NTP activities such as training and supervision.
The responsibility for funding, procurement and distribution of anti-TB drugs became
centralised and removed the patchwork arrangement of each implementing INGO
arranging its own drug supplies. Laterally external funding for the drug budget came
from NORAD and more recently DfID has taken on a commitment to fund this key
element of the programme. The partnership of external and in-country INGOs has

25
   Tuberculosis Control in Nepal 2055-2060 (1998-2003) Long Term Plan, NTP/MoH/HMG,
Kathmandu, 1999
26
   Tuberculosis Control in Nepal 1995-1999, HMG/N & WHO, Kathmandu 1995
27
   Dr Christian Gunneberg, Medical Officer, TB, WHO Nepal - Personal communication May 2003
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 42


been greatly strengthened in the past 8 years through the 6 monthly NTP technical
reviews and the annual Technical Advisory Group (TAG) meetings when
government, financial and in-kind donors can meet to exchange views and jointly
assess progress.

Mechanisms for funding provision:
Despite the increased presence and communication of donor partners it remains
difficult to fully collate the funding streams that underpin the work of the NTP. This
is due to the varied mechanisms that regulate each supporting donor budget. There is
a clear requirement to more formally map out the contributions, both in funding and
in-kind if the complete resource envelope is to be quantified. This would require
increased transparency from Ministry of Health, NTC, and the donor partners.
The mechanisms through which resources are currently channelled to the NTP are:

Government:
        Regular Budget: This budget is allocated only for staff salaries,
        administrative activities and other operational costs of the National
        Tuberculosis Centre. This is shown in the ‘red book’ of the Ministry of
        Finance and released on a trimesterly basis.
        Development Budget: This budget is primarily for the programme
        activities such as drugs and supplies, training, microscopy, supervision and
        monitoring. A proportion of the development budget is allocated to
        districts for district level activities. This budget is also shown in the ‘red
        book’.

Donor mechanisms:
         Funds are provided direct to HMG: (eg LHL, WHO, JICA)
             o Through Ministry of Health
             o Through Department of Health
         Funds are provided by one donor but channelled to NTP through WHO (eg
         DfID provides funds via WHO)
         Funds are provided by one donor but channelled to NTP through an in-
         country implementing INGO (eg DfID provides funding through the work
         of INF)
         In country implementing INGOs who provide a considerable volume of
         services in kind but no financial flows (eg INF, BNMT, GENITUP)
         National NGO’s who provide resources in kind but no finances (eg
         NATA)

Unfortunately not all these donor streams are recorded in the official government
budget document known as the Red Book. There is therefore currently no one source
that can identify all contributions either as cash or kind which are assigned to the
support of TB control in Nepal through the National TB Programme.


Donor base profile:
The Nepal TB Programme is fortunate to have a broad and committed donor base.
This has grown over the past 10 years and in general the trend has been for new
donors to express interest rather than established donors to withdraw. Over the past 5-
10 years a natural progression towards a sub-sectoral ‘basket funding’ arrangement
has evolved within the donor contributions such that now donors have distinct areas
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                       Page 43


of the ‘NTP cake’ that they clearly fund eg; JICA for microscopy, LHL for training
and supervision, INF for mid west implementation. The table below outlines the areas
of assistance of the NTP donor partnership.
Development Partners over the period 1998 - 2003
Agency                                      Support Main Activities                        Remarks
National Level
                                                                                           Has provided funding for
                  DfID                         T, F      Anti-TB drugs                     WHO MO and five
                                                                                           regional TB co-ordinators
 International Union Against TB
                                               T, R      DOTS expansion                    Technical agency for LHL
       and Lung Diseases
                                                         Lab materials,           Phase 2 project concluded
                                                         equipment, urban TB      mid 1999 followed by
                  JICA                         T, G
                                                         programme support        Community TB and Lung
                                                         (KTM)                    Health Project
      Japanese Government                       G        Drugs                    From Debt Relief Fund
     Norwegian Heart & Lung                                                       New proposal to be
                                               T, F      Training and supervision
        Association (LHL)                                                         negotiated from 1999
                                                                                  Has provided buffer
                NORAD                            F       Drugs
                                                                                  stocks of TB meds
                                                         DOTS in hard to access
                                                         areas, involvement of
 Nuffield Institute for Health, UK             T, R                               No budget to NTP
                                                         Private Sector in TB
                                                         control using DOTS
        Research Institute of
                                                R        DOTS                              No budget to NTP
        Tuberculosis, Japan
                                                         Training, surveillance,
                 WHO                           T, F
                                                         advocacy
         Regional Level
   Britain Nepal Medical Trust
                                                 I       East                              No budget to NTP
             (BNMT)
 International Nepal Fellowship
                                                 I       Mid West                          No budget to NTP
               (INF)
   Netherlands Leprosy Relief
                                                 I       Far West                          No budget to NTP
              (NLR)
          District Level
   Friends of Shanta Bhawan                      I       Kathmandu                         No budget to NTP
                                                         Kathmandu, Parsa,
    German Nepal TB Project
                                                 I       Bara, Rautahat and                No budget to NTP
         (GENETUP)
                                                         Mohattari
                                                         Parbat, Myagdi,
                                                         Baglung, Gulmi,
    Medicin du Monde (MDM)                       I                                         No budget to NTP
                                                         Arghakhachi, Syangja,
                                                         Palpa
    Nepal Anti TB Association
                                                 I       28 districts                      No budget to NTP
            (NATA)
                                                         Lalitpur, Okhaldhunga,
 United Mission to Nepal (UMN)                   I                                         No budget to NTP
                                                         Gorkha, Palpa
Key
Technical support:                              T
Financial support:                              F
Gifts in kind:                                  G
Implementation:                                 I
Research:                                       R

Table 6: Development Partners 1998-2003
Source: Tuberculosis Control in Nepal 2055-2060 (1998-2003) Long Term Plan, NTP/MoH/HMG, Kathmandu,
1999 and current updates by NTC
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002          Page 44




The ability of the NTP to use ‘released funds’
One of the measures of the ‘capacity’ of a programme or department is its ability to
use the funds allocated for activities within the proposed time scale. The NTP has
demonstrated good planning and implementation management as measured by the
percentage of ‘released funds’ to ‘released budget’.

                             HMG Development Budget for NTP
                   140,000
                                                                                           100%
                   120,000
                                                                                           80%
                   100,000
  Nepali Roupees




                    80,000                                                                 60%

                    60,000
                                                                  Allocation               40%
                    40,000                                        Expenditure
                                                                  Percentage used          20%
                    20,000

                        0                                                                  0%
                             97/98   98/99          99/00          00/01          01/02
                                           Nepali Fiscal Year

Figure 6: Ability of NTP to utilise available HMG Development Budget allocation
Source: Ministry of Finance, Annual Budget Statement (Red Book) FY 2054/55 to 2059/60


Another factor which can influence the ability of an NTP to effectively use donated
funds is the manner in which the funds are disbursed. The LHL approach was to
provide an annual commitment of a lump sum directly to the NTP based on a detailed
annual plan. There were few limitations on how the money could be spent but an
insistence on a strong annual independent audit. This approach was found to be
extremely effective in enabling the NTP to spend money easily whilst ensuring
accountability and a clear audit trail. Noticeably disbursement of LHL funds tended to
be at a much higher rate than other donor funds as a result.

The prospects for the next 5 years
Informal discussions with donor partners during the review process suggested that the
donors are in general very favourable to the future needs of the NTP. However the
diverse nature of the donors reflects differing viewpoints on the best way to channel
funding to the control of TB in Nepal. Two of the key implementing in-country NGOs
(INF and BNMT) are currently undergoing major internal restructuring which is
likely to lead to a downsizing of NGO assisted TB focused activity in the Eastern and
Mid-Western Development Regions. LHL remains strong in its resolve to assist the
NTP in the key areas of training and supervision. The JICA project has adjusted its
focus from pure TB technical assistance to that of ‘adult lung health’. It remains to be
seen how the Department of Health responds to this new syndromic approach to lung
health. DfID is the strongest advocate for a sector wide approach and is likely to
support any endeavours to integrate and decentralise TB control within the health
sector. As Nepal is seen as a key ‘model’ for other countries in the South Asia region
and hosts both the SAARC TB centre and the annual WHO/IUATLD TB programme
managers training course we would expect WHO and IUATLD to demonstrate high
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002         Page 45


levels of ongoing technical support into the near future. The NTP has not applied for
funding of its national drug requirements from the Global Drug Facility (GDF) as
currently DfID support this budget line. As the GDF is actively promoting countries
to apply we would predict that Nepal will submit a proposal in the next 5 years.

The positive and negative implications of the HSR process on
sustained resourcing of the NTP
TB Control is well positioned as a public health intervention to receive priority
funding under the requirements of any HSR process. The overarching objectives of
reform are summarised as efficiency, equity and quality and on each of these
parameters TB control has the potential to score highly28. TB services using the
IUATLD/WHO programme model demonstrate both allocative and technical
efficiency. Cost-benefit studies have demonstrated the strategic value of investment in
national TB control. In terms of equity, TB control demonstrates a bias towards the
poor which is highly valued as a feature of the restructuring of health services.
Quality is demonstrated in the emphasis on cohort outcome reporting which provides
clear measures of programme performance and the inbuilt community oversight
element inherent in the DOTS methodology. Thus on empirical grounds, TB control
should be prioritised within HSR processes.
The elements of HSR which could be detrimental to the TB programme are:
        Loss of donor partners that have traditionally supported TB control if there
        becomes no funding mechanism through which they can earmark their
        donations to TB control.
        Decentralisation of budget planning to district level could lead to TB services
        being de-prioritised at a local implementation level.
        Lack of adequate funding during any transitional phase of HSR
        implementation.


Recommendations regarding NTP funding
1. Public sector TB diagnostic and treatment services should remain free of charge at
   the point of delivery.
2. A fully costed 5-year forward plan in English (for scrutiny by donor community)
   is required to build on the firm foundation of the two earlier 5-year plans 1995-
   1999, 1998-2003. (Nepali version is available)
3. At present there would appear to be no centralised comprehensive record of
   funding (or in-kind contributions) from each donor and implementing agency.
   This should be rectified.
4. The good relationships between the NTP and donor partners & implementing
   NGOs should be retained through any HSR process by means of the established
   Technical Advisory Group meetings. The group might wish to meet more
   frequently during the HSR implementation phase.
5. The capacity of the current in-country implementing INGOs to support the NTP in
   the next 5 years should be explored and agreements secured.
6. Applications to the Global TB Drug Facility should be considered as this would
   allow donor funds to be reinvested into other aspects of the programme.




28
  Weil, D E C. Advancing tuberculosis control within reforming health systems. Int J Tuberc Lung Dis
1998;2:349-359
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 46




Lessons for the Region
Success factors
Success of the TB programme in Nepal as measured by internationally accepted
outcome and programme indicators is clearly evident. But what were the ingredients
of that successful recipe? And can it be replicated in other programmes in Nepal or
indeed in other nations? This section seeks to identify the ‘why’ and the ‘how’ of the
Nepal NTP success. A major component in the success of the adoption of the DOTS
strategy in Nepal lies in the structured and phased manner in which the key operations
for implementation were addressed. The WHO Stop TB Programme issued an
expanded DOTS Framework for Effective TB Control in 200229 and identified a set of
key operations required. These key operations are used as a template in this report for
analysing the Nepal programme:

1. Presence or establishment of a National Tuberculosis Programme
(NTP) with a clearly identified central unit
In Nepal the presence of a large and well equipped purpose built outpatient, office and
training facility known as the National TB Centre located some 30 minutes drive from
the Department of Health Services (DoHS) has given the TB programme a clear
physical and operational identity. The same building also houses the SAARC TB
Centre which provides a synergy of additional TB technical resources. This was an
advantage for the NTP in terms of office resources and a degree of autonomy from the
activities within the DoHS. The resultant managerial distancing from other DoHS
programmes and national centres also had a negative side in hampering the
networking between the NTP and other programme.

Learning Point: The early provision of adequate central unit office facilities for the
NTP is often not considered. Such facilities should be located within or near the
DoHS.

2. Preparation of a programme development plan for the NTP based on
findings of a systematic review of the prevailing situation, with details
on budget, sources of funding and responsibilities
The creation of just such a document prepared within months of a detailed country
review by the WHO and IUATLD was undoubtedly a powerful driver for the DOTS
implementation strategy and a focal instrument to attract HMG and donor funding.
The draft 5-year plan prepared in late 1994 was widely discussed leading to
ownership by the TB related INGOs in the country. The choice and continuity of the
WHO short tem consultant who prepared the plan and then was contracted to provide
technical assistance for its implementation was another significant success factor.

Learning Point: A robust national review leading quickly into the preparation of a
development plan can provide the focus to harness political, donor and INGO
support. The choice of consultant is important as is the requirement for continuity of
leadership of the NTP director and any external technical support consultant in the
early stages of any major revision of the NTP.


29
 An Expanded DOTS Framework for Effective Tuberculosis Control, WHO/CDS/TB/2002.297,
WHO 2002, Geneva
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 47


3. Preparation of a national programme manual containing: NTP aim,
objectives, policy, strategy, programme structure, job descriptions, case
definitions, case finding, diagnosis and treatment guidelines,
instructions for reporting formats, logistics, and supervision
The preparation of the Nepal TB Manual was a key process as well as an outcome. It
was drafted originally in English with full participation of senior managers in the NTP
plus the active involvement of the Tuberculosis Control Network (TBCN) which
divided into short term working groups to tackle component parts. Once ratified it
was translated into Nepali and widely distributed. Adequate budgeting of both time
and money for the drafting, translating, adequate print runs and final distribution gave
this document the status, quality and exposure needed to drive the extensive change
process.

Learning Point: A weak manual leads to a weak programme. A well developed
national TB manual prepared in advance of any implementation is a solid foundation
for introducing the other programme elements such as training and supervision.

4. Establishment of the DOTS recording and reporting system
The IUATLD/WHO reporting system, centred around the capacity to generate
quarterly cohort outcomes for a district population of approximately 100,000
population, was accepted as national policy. Local adaptations were made such as
reporting cohorts on a 4 monthly basis to align reporting with national government
practice. The transfer of patients to the revised registers, recall of previous reporting
systems and correct completion of the new forms required initial intensive training
and strict supervision.

Learning Point: As with the TB manual the introduction of the reporting
documentation requires to be handled as a project in itself. Materials, training and
subsequent supervision are all required.

5. Plan and initiate a training programme covering all aspects of the
policy package and prepare a plan for training regional and district
primary health care staff and laboratory technicians involved in the TB
programme
From the start of the DOTS programme a donor partner (LHL) took responsibility to
fund the required training programme. At the national level the WHO modular
training package was used extensively for the training of trainers (TOT). Training
materials were devised for all cadres of health care workers ranging from the District
Health Officers to Female Community Health Volunteers (FCHVs). As the
programme expanded training was targeted at health support staff such as
storekeepers and statistical assistants. Provision was also made for training or
orientation of community groups, local NGOs and most significantly the ‘DOTS
Committees’ who then ensured local accountability for DOTS treatment centres.

Learning Point: Three issues stand out. First the availability of adequate financial
resources to back a comprehensive, locally adapted, rolling training programme.
Secondly the widespread use of the WHO training modules to increase technical
capacity for senior staff and trainers. Thirdly the expansion of training into generic
health care support roles and wider civic society.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002           Page 48


6. Establish a microscopy services network with binocular microscopes
and adequate ancillary equipment and with laboratory technicians
trained in sputum smear microscopy
Another donor partner (JICA) took responsibility to address this need. The provision
of binocular microscopes, widespread training and the setting up of regional quality
control laboratories has significantly improved the quality and access of sputum
microscopy. However frequent transfer of microscopy technicians has often hampered
the development of this service in less accessible areas. Nepal would appear to be one
of the few countries in the region with a functioning smear microscopy quality control
mechanism. This should be recognised as a major achievement. The emphasis on
quality of diagnosis has played a significant part in convincing private doctors to refer
patients for microscopy rather than relying on radiology.

Learning Point: Recognition of the crucial importance of available microscopy
services for a functioning DOTS programme requires that priority is given to the
allocation and retention of trained staff to DOTS treatment centres. The presence of a
quality control programme has ensured diagnostic standards are maintained.

7. Establish treatment services within the primary health infrastructure
where directly observed short course chemotherapy is administered
Nepal’s initial experience with DOTS was an overhasty implementation in 6 districts.
The errors of this were picked up at the annual external review and the NTP revised
its planning process to generate a more robust approach. Central to this was the
establishment of 4 ‘National DOTS Demonstration Centres’, the development of a
10-point checklist30 for the inclusion of a potential health care facility to be adopted
as a DOTS treatment centre. The backbone of the service is delivered through PHCs
or Health Posts but also extends to Medical Colleges, district, regional and tertiary
hospitals. Local and international NGOs also provide DOTS treatment facilities.
Standardised treatment regimens (categories I, II & III) are used. The spectrum of
‘direct observation’ varies from the gold standard of 6 day a week attendance at the
health facility and administration of the medicines under the eyes of the health care
worker to ‘community’ or ‘family-based’ DOTS research areas. In community based
DOTS an appointed community member such as a Female Community Health
Volunteer (FCHV), Village Health Worker (VHW) or Maternal and Child Health
Worker (MCHW) and in family based DOTS a reliable family member identified by
the patient will observe the daily administration of the medicines. Operational
research is ongoing but interim results would suggest that there is little difference in
final cure rates in both strategies.

Learning Points: The DOTS expansion programme consisted of a comprehensive
package of new site selection and preparation based on the 10-point checklist. Public
(PHC and hospital), private and NGO facilities were used for service delivery.

8. Secure a regular supply of drugs and diagnostic materials based on
previous case notification data
This ‘DOTS pillar’ includes the budgeting, procurement, quality assurance, shipping,
warehousing, in country distribution system, local stock keeping, buffer stocks and
quarterly reporting mechanism. In Nepal the budget for drug supplies has at times

30
  The ’10 Steps to DOTS’ was later developed into a short manual that was printed and distributed to
other NTPs by SEARO.
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 49


been precarious. Currently one donor (DfID) is fully supporting this area for a 5-year
period. The NTP has felt this area to be of such importance that it has sought interim
but robust delivery systems using the major implementing INGOs in the 3 more
remote regions and used central and regional TB dedicated resources for distribution
in the other 2 regions. This is in essence an unsustainable and vertical mechanism but
has ensured the uninterrupted supply of drugs from centre to district from where the
local health service takes responsibility to deliver drugs to treatment centres.

Learning Points: The management of drug supply has been closely monitored and
controlled by the central unit and implementing regional INGOs. This has provided
the fast expanding programme with the security of uninterrupted supplies. However
the consolidation phase of the DOTS coverage programme must include mechanisms
to integrate the NTP logistic chain into the responsibilities of the generic DoHS
Logistics and Management Division.

9. Design a plan of supervision of the key operations at the regional and
district level to be implemented from the start of the programme
In Nepal one of the early signs of government commitment to the strengthening of its
NTP was the creation and salary provision of regional and district level supervisor
posts with joint responsibility for TB and Leprosy. Known as Regional TB/Leprosy
Assistants (RTLAs) and District TB/Leprosy Assistants (DTLAs) these appointments
provided a structure through which the NTP could deliver a quality of supervision and
data reporting above the capacity of the basic district health services. In addition
implementing INGOs were able to provide counterpart district and regional TB
dedicated staff to capacity build this new cadre of staff. Finally, one of the donor
partners chose to support the entire supervision programme and provided the
necessary funding (including motorbikes for terai districts) for comprehensive field
supervision at all levels. In response to an NTP review team recommendation, WHO
with the help of DfID has recently recruited five regional tuberculosis co-ordinators to
help NTP at the regional level. This new cadre of regional technical managers should
help to strengthen NTP implementation capacity and permit more efficient planning at
the regional level.

Learning Points: The supervision programme is an example of excellent partnership
working between government staff, ring fenced donor support, and local capacity
building and practical support by’ on the ground’ INGOs.


Additional Key Operations
10. Information, Education, Communication (IEC), Advocacy and Social
Mobilisation
An emphasis on ‘communication’, whether it be in the form of advocacy to
politicians, education to patients and their families or grass roots mobilisation of
communities is a marker activity of a thriving and positive NTP. Throughout the mid
and late 1990’s a Health Education subgroup of the TB Control Network (comprising
INGOs, local NGOs and the NTP) drove forward the development of tools and
strategies for effective communication for use across the country. Much emphasis was
placed on tapping into the power of the local and national media to communicate
information to the public and indeed politicians. It became standard practice to release
press statements and invite press reporters to attend events such as the opening of a
new treatment centre or a planned street drama based on TB. World TB Day was
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002           Page 50


developed into a major event attracting considerable media and political attention.
Perhaps the most innovative and strategic action was the training of cohorts of media
reporters from across Nepal and South Asia through a joint partnership between the
Panos Institute for South Asia31 and the NTP/STC/WHO.
Communication and networking were key themes that underpinned the extraordinary
success of the TbNet organisation which arose in Kathmandu from a desire to bring
together TB activists, managers and health professionals.

Learning Points: While demonstrated in a multitude of ways the emphasis on
proactive communication and networking at all levels was instrumental in the success
of the programme as a whole. In particular the partnership working between the NTP
and the press provided wide local and national press and radio coverage, increasing
awareness of, and confidence in, public attitudes towards TB and its treatment.

11. Involving private and voluntary health care providers
The history of TB control in Nepal is closely linked to the work of NATA, (Nepal
Anti-TB Association) the national NGO dedicated to TB and a significant number of
INGOs who provided a patchwork of TB treatment services ranging from a single
urban clinic to a multi-district programme. As these agencies met together under the
umbrella of the TBCN, other agencies for which TB was a component activity were
invited to join. As the momentum grew and DOTS was expanded approaches were
made to link with urban private practitioners, community health programmes, private
medical institutions and even some development work with traditional healers in the
mountain districts. Particular efforts have been made to involve the expanding urban
private medical sector with some excellent results. In 1998 a project entitled the
Kathmandu Valley Coalition Against TB (KV-CAT) was launched to develop DOT
provision in the urban setting. A Public-Private-Partnership (PPP) was initiated in
Lalitpur Municipality in the same year. The Lalitpur Urban TB Programme is now
seen as a model in forging operational partnerships with the private sector in TB
control. Pathfinder examples are Hargan’s Nursing Home in Lalitpur and the UMN
YALA Urban Health Programme (YUHP), both of which are part of the Lalitpur
Urban TB Programme. With the experience gained from Lalitpur Urban TB
Programme the NTP has now expanded the urban DOTS programme across
Kathmandu Metropolitan City where more than five different stakeholders are
supporting urban DOTS. Another area of involvement with the private sector has
been the development of DOTS demonstration centres in each of the 6 private
teaching hospitals in Nepal and the inclusion of DOTS within the medical school
teaching curriculi.

Learning Points: The Nepal programme had a culture of working with different
agencies in the control of TB which promoted the inclusion of new private and
voluntary partners. Work with the private sector has been slow and challenging but is
now bearing fruit. The building of trust and co-operation with private practitioners
must be earned and this takes time.




31
  Panos Institute South Asia is based in Kathmandu and works to build the capacity of media to
improve coverage of vital development issues, encourage cross-border perspectives and better regional
interchange of information. GPO Box 13651, Kathmandu, Nepal
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 51


12. Economic analysis and financial planning
The 1993 World Bank Report graphically demonstrated the cost effectiveness of TB
control as a public health measure. Using the tools of health economic analysis NTPs
have the potential to demonstrate the utility of TB control to national planners and
politicians. In Nepal there has been little work in this field although recently a health
economics unit has been set up in the Ministry of Health.32 The NTP has prepared two
five-year budgets (1995-1999 and 1998-2003) both of which have been instrumental
in the approach to external donor partners. The linkages between central financial
planning mechanisms in the Health Ministry and that undertaken within the National
TB Centre appears weak, however within the NTP itself resource requirements are
identified and appropriately incorporated into budget planning. The NTP would
appear to engage external technical assistance from WHO and donor partners in the
preparation of annual budgets however it has been more effective and flexible in the
mobilisation of available funds within its control.

Learning Points: The application of health economics is weak in the Nepal health
system and this is reflected in the NTP. The NTP has effectively resourced external
assistance in the process of budget formulation and achieved good release of funds.

13. Operational Research
The promotion of operational research has been an integral aspect of the NTP largely
due to the technical assistance of the ongoing JICA Community TB and Lung Health
Project which has strong links with the Research Institute of Tuberculosis (RIT) in
Tokyo. Latterly the Nuffield Institute for Health (NIH), UK has set up a research
programme based within the NTP. For many years WHO has been running TB drug
resistance surveys and TB-HIV surveillance. Nepal also collaborates in international
studies with the IUATLD on drug regimes and drug resistance patterns. These
linkages between renowned academic institutions and staff within the NTC have
woven operational research into the fabric of the programme. Additionally, the
counterpart INGOs, particularly BNMT and GENETUP have a strong pedigree for
publishing TB related research.

Learning Points: The attention given to practical operational research has driven up
technical capacity of both individuals and the programme as a whole. The current
research partnerships are an additional stimulus to quality improvement. Investing in
operational research has been of true benefit to the NTP.




32
     Health Economics & Financing Unit, Ministry of Health was established in July 2002
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 52




Thanks
We should like to express our thanks to the following institutions and individuals:

Lanarkshire NHS Board, NHS, UK for release of Dr Hamlet to undertake this work
Nuffield Institute for Health, UK for release of Mr Baral to undertake this work
Dr Diana Weil, World Bank, Washington
Dr Christian Gunnerberg, Medical Officer, WHO, Nepal
Dr DS Bam, Director NTP, Nepal
Dr Tirtha Rana, World Bank, Nepal
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 53




Annexes
Annex 1: Terms of Reference

Annex 2: Map of Nepal

Annex 3: Organisational Charts

Annex 3a: Organisational chart of Ministry of Health

Annex 3b: Organisational chart of Department of Health
Services

Annex 3c: Organisational chart of National TB Centre

Annex 4: Tables, Graphs and Figures

Annex 5: List of key people interviewed

Annex 6: List of background materials examined

Annex 7: List of external peer reviewers
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 54



Annex 1: Terms of Reference

Purpose: To produce a case study analysis of the National Tuberculosis Program
          in Nepal.

Specific objectives:

(a) To provide lessons for public health, primary care and health sector
development in Nepal based on the successes and remaining challenges of the TB
control program and its integrated service delivery system. The analysis will examine
how the program is structured, how required public health functions are pursued, and
a whether a focus on results, impact and accountability is fostered. It will also
address the means of collaboration among the Government, non-Governmental
organizations, communities, donors and technical assistance agencies. Furthermore,
the analysis would examine how future plans for health sector programming In Nepal
might strengthen and further enable adaptation and expansion of the TB program and
how the program might contribute to the development of the sector program goals and
strategies.   Nepal’s National TB Program has been noted as one of the most
successful public health initiatives in the country and merits exploration. This analysis
should be informed by ongoing actions in MOH with regard to the development of
"Health Sector Strategy - An agenda for change" and the preparation process and
progress of "Nepal Health Sector Program - Implementation Plan" in collaboration
with the external development partners.

(b) To assess the level of funds available for the National TB Program from public
and external sources - historical trend, assurance of financing for next 3-5 years.
Although Tuberculosis control is one of the Priority one (P1) projects of the
Government out of 17 P 1 projects as defined in the Medium Term Expenditure
Framework (FY 03-05), the support services may not be adequately met through the
projected level of allocation and it is likely to pose a risk for future program
implementation.      The author can then present views on the potential resource
envelope and additional options for the period of the PRSP (FY 03-07).

(c) To summarize lessons for other countries on local adaptation and application
of the recommended TB control strategy, known as DOTS. Nepal has been
consistently seen as a good performer in TB control since the DOTS approach was
adopted and expanded in the 1990s. The Director of TB program now directs as well
a regional technical advisory service for TB control in South Asia. While there are
challenges that remain in Nepal particularly in case detection and gender differences,
the successes in a very low resource environment have been impressive and results
have been widely published. However, further analysis is merited on the socio-
economic, human resource, institutional and financial characteristics that may
contribute to this success as well as inhibit even greater speed in reaching global TB
control targets and the communicable disease control Millennium Development Goal
(MDG).
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 55



Annex 2: Map of Nepal
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                                                                                                                                     Page 56


Annex 3a: Organisational chart of Department of Health
Services

                                                                                       Ministry of Health

                                                                     Department of Health Services


                           DIVISIONS                                                                                                                                                           CENTRES




                                                                                                                                                                                      NHEICC




                                                                                                                                                                                                                                  NCASC
                                                                                                                                                   NHTC
                                   EDCD




                                                                        HIMD




                                                                                                                                                                                                                                          NPHL
     PFAD




                         CHD




                                                 LMD
              FHD




                                                                                                                                                                                                   NTC
                                                                                                              LCD
CENTRAL                                                    Central Hospitals
LEVEL
                                                                    Regional Health Services Directorate




                                                                                                                                                          Regional Medical Store(5)
                                                                               Regional Training Centre (5)




                                                                                                                         Regional Laboratory (1)




                                                                                                                                                                                                    Regional TB Centre (1)
                                            Regional Hospital (1)




REGIONAL
LEVEL
ZONAL
LEVEL(14)                                                                                        Zonal Hospital - 11

DISTRICT                         District Public                                                                District Hospital                                                              District Health
LEVEL (75)                      Health Office (14)                                                                    (59)                                                                      Office (61)


ELECTORAL                                                                        Primary Health Care Centre /
CONSTITUENCY (205)                                                                   Health Centre (172)

                                                                                                                    Health Post (710)


VDC LEVEL (3,995)                                                                                             Sub Health Post (3,132)


COMMUNITY LEVEL                        FCHV                                 TBA                                                  PHC Outreach                                                     EPI Outreach
                                      47,261                               15,554                                                   15,349                                                            15,201
    Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 57




Acronyms

PFAD: Planning and Foreign Aid Division
NHEICC: National Health Education, Information and Communication Centre
FHD: Family Health Division
CHD: Child Health Division
NTC: National Tuberculosis Centre
EDCD: Epidemiology and Disease Control Division
NCASC: National Centre for AIDS and STD Control
LMD: Logistic Management Division
NPHL: National Public Health Laboratory
HIMDD: Health Institution and Manpower Development Division
FCHV: Female Community health Volunteer
LCD: Leprosy Control Division
PHC: Primary Health Centre
NHTC: National Health Training Centre
EPI: Expanded Programme of Immunisation




    Source: DoHS, Annual Report 2057/58 (2000/2001)
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                             Page 58


Annex 3b: Organisational chart of National TB Centre




               Organisational Chart of the NTP
  Responsibilities
                                                     Ministry of Health

 Co-ordination of the NTP                            Director General
 within the health services                          of Health Services
 Technical policies for the NTP
 Planning, Monitoring and Evaluation                  National Tuberculosis Programme/
 Training, Supervision and Research                  National Tuberculosis Centre, Director           Other National
                                                                                                        Centres &
 Management of the NTP at the                                                                        Divisions of DOH
 Regional Level                        Regional Directors
                                                                                                    NCASC PFAD
 Training and Supervision                                                                           NPHL     EDCD
 Monitoring
                                                                 RTC/RTLA
                                                                                                    NHTC     LMD
 Management of the NTP at the         District Health                                DOTS           NHEICC HRDD
 District Level                          Officers                                   committee       AIDS Centre
                                                                DTLA                                CHD      FHD
 Diagnosis, tratment and
 Monitoring                      Primary Health Centres
                                                                         NGOs              KEY
 Case Holding and                      Health post                                         Main Structure of NTP
 Treatment                                                                                               Line Management
                                                                                                         Technical Supervision
 Case Holding / Tracing            Sub Health Posts               Communities
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 59



Annex 4: Tables, Graphs and Figures
Annex 4a: NTP 5 year budget summary 1998-2003
Annex 4b: HMG Finance Ministry (Red Book) budget figures 1998-2003
Annex 4c: Contribution of JICA
Annex 4d: Contribution of LHL
Annex 4e: Contribution of NORAD
Annex 4f: Contribution of DfID
Annex 4g: Contribution of WHO
Annex 4h: Epidemiological assumptions of NTP plan 1998-2003
Annex 4i: TB Case notification in Nepal 1972-2002
Annex 4a: NTP 5 - year budget summary 1998-2003

NTP Five Year Plan 1998-2003
                                                   1998/1999                                1999/2000                                2000/2001
                  Heading               Budget       HMG            Balance      Budget       HMG            Balance      Budget       HMG          Balance
Diagnosis
Diagnostic supplies                     131,174          -          131,174      146,954      62,455          84,499      164,609      74,074        90,535
Treatment
Medicines                              1,166,026    411,387         754,640     1,730,361    493,664        1,236,696    2,049,180    592,397      1,456,783
Training
Fellowship                               65,000          -           65,000       49,500          -           49,500       78,650            -       78,650
In-service training                     144,500          -          144,500      158,875      67,522          91,353      174,684      78,608        96,076
Miscellaneous                            31,000      12,400          18,600       34,100      14,493          19,608       41,261      18,567        22,694
Supervision
Supervision                              24,480      18,000           6,480       26,928      19,800           7,128       29,621      21,780         7,841
Surveillance and Research
Surveillance                             18,000          -           18,000       23,800      10,115          13,685        9,680       4,356         5,324
Research                                110,000          -          110,000      145,000          -          145,000      130,000            -      130,000
Advocacy & Education
Advocacy                                 15,750          -           15,750       17,325       7,363           9,962       19,058       8,576        10,482
Education                                44,750      20,000          24,750       49,225      20,921          28,304       54,148      24,366        29,781
Equipment and Vehicles
Equipment and Vehicles                  168,199          -          168,199       46,419          -           46,419       51,061      22,978        28,084
Institutional cost
NTC and RTC                             135,901     135,901               -      149,491     149,491               -      164,440     164,440             -
Technical Assistance
Technical Assistance                    891,435          -          891,435      676,813          -          676,813      770,219            -      770,219
Total                                  2,946,215    597,688        2,348,528    3,254,791    845,824        2,408,967    3,736,611   1,010,142     2,726,469
NTP contribution excluding Tech Asst                         29%                                      33%                                    34%
Overall Contribution                                         20%          80%                         26%          74%                       27%          73%
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                          Page 61




   NTP Five Year Plan 1998-2003 (cont)                            2001/2002                                     2002/2003                                TOTAL
                      Heading                      Budget            HMG             Balance         Budget       HMG         Balance       Budget        HMG           Balance
Diagnosis
Diagnostic supplies                                 184,825            87,792          97,033        206,450     103,225       103,225       834,012      327,546        506,466
Treatment                                                                                                                                         -             -                 -
Medicines                                         2,421,158       71,087,650         1,710,282      2,777,049    853,052      1,923,997    10,143,774   73,438,150      7,082,398
Training                                                                                                                                          -             -                 -
Fellowship                                           59,895                -           59,895         95,167            -       95,167       348,212            -        348,212
In-service training                                 173,435            82,382          91,054        108,703      54,351        54,351       760,197      282,863        477,334
Miscellaneous                                        54,918            26,086          28,832         80,406       40,203       40,203       241,685      111,749        129,937
Supervision                                                                                                                                       -             -                 -
Supervision                                          32,583            23,958              8,625      35,841       26,354        9,487       149,453      109,892         39,561
Surveillance and Research                                                                                                                         -             -                 -
Surveillance                                         23,648            11,233          12,415         31,713       15,856       15,856       106,841       41,560         65,280
Research                                             20,000                -           20,000              -            -            -       405,000            -        405,000
Advocacy & Education                                                                                                                              -             -                 -
Advocacy                                             20,963             9,958          11,006         23,060       11,530       11,530        96,156       37,427         58,730
Education                                            59,562            28,292          31,270         65,518       32,759       32,759       273,203      126,338        146,864
Equipment and Vehicles                                                                                                                            -             -                 -
Equipment and Vehicles                               93,967            44,634          49,333         93,284       46,642       46,642       452,930      114,254        338,677
Institutional cost                                                                                                                                -             -                 -
NTC and RTC                                         180,884           180,884                -       198,972     198,972             -       829,688      829,688              -
Technical Assistance                                                                                                                              -             -                 -
Technical Assistance                                806,816                -          806,816        881,723            -      881,723      4,027,006           -       4,027,006
Total                                             4,132,654       71,582,869         2,926,561      4,597,886   1,382,944     3,214,940    18,668,157   75,419,467     13,625,465
NTP contribution excluding Tech Asst                                           36%                                      37%                                      35%
Overall Contribution                                                           29%            71%                       30%          70%                         27%           72%
Assumptions:
HMG contribution to most budgets initially 40%, increasing annually by: 2.50%
HMG drug contribution increases by 20% per year
HMG staff costs other than those in NTC and RTC not shown. Project staff (regional supervisors and central unit staff) only shown.
Supervision cost for project staff only- other supervision cost in HMG budget.
Cost per patient treated:      $ 118
Cost per patient cured:        $ 139
Cost per life saved:           $ 303
Annex 4b: HMG Finance Ministry (Red Book) budget figures 1998-
          2003

Central level development budget allocation for NTP reflected in ‘Red Book’
                       HMG                         Donor              Total US$
    Year                  NRs. (,000)   US$ (,000)     NRs. (,000)     US$ (,000)       (,000)
1997- 1998                  31,700             412         -               -                 412
1998- 1999                  26,302             342        25,560         331.95              674
1999- 2000                  10,000             130       100,000          1,299            1,429
2000- 2001                  12,760             166       110,702          1,438            1,603
2001- 2002                  29,300             381        79,300          1,030            1,410
2002- 2003                  19,602             255        83,499          1,084            1,339



HMG Total Development and Regular Budget for NTP
reflected in ‘Red Book’
              Development Regular
    Year         Budget   Budget     Total (US$)
               (US$ 000)   (US$)

1998- 1999                     674          46,494      720,494
1999- 2000                   1,429          43,506     1,472,506
2000- 2001                   1,603          74,312     1,677,312
2001- 2002                   1,410          60,610     1,470,610
2002- 2003                   1,339          84,390     1,423,390




                                     NTP Budget (Development and Regular)

                                                                1,677,312
                1,800,000
                                                1,472,506                        1,470,610     1,423,390
                1,600,000
                1,400,000
                1,200,000
   Budget US$




                1,000,000
                                 720,494
                 800,000
                 600,000
                 400,000
                 200,000
                      -
                                  1998-99        1999-00         2000-01         2001-02           2002-03
                                                            Nepali Fiscal Year
Annex 4c: Contribution of JICA

Contribution of JICA to NTP Nepal (US$)
Year Contribution                                               Amount in US$
     Equipment - vehicle, computer, microscope (17),
1994 photocopier and others                                                 170,109
     Drugs                                                                  376,997
     Local cost                                                             123,338
1995 Equipment - vehicle, microscope (3) and others                         154,035
     Drugs                                                                  416,635
     Local cost                                                             194,322
1996 Equipment - microscope (34) and others                                 376,068
     Local cost                                                             147,482
1997 Equipment - microscope (50) and others                                 225,645
     Local cost                                                             192,283
1998 Equipment - microscope (50) computer(3) and others                     217,015
     Local cost                                                             214,000
1999 Equipment – Motorbike (5), computer (1) and others                      36,490
     Local cost                                                             161,700
                                                          Total             3,006,119
Source: Report on JICA TB Control Phase II (5th July 1994- 4th July 2000)




Annex 4d: Contribution of LHL

LHL support to NTP Nepal (US$)
               Heading               1998     1999         2000       2001   2002          Total
Material production                  22,056 23,579         32,136    32,136 25,183       135,090
Resources                             5,467   9,595          8,921    8,921  7,877        40,781
Staff development                    12,432 13,798          13,712   13,712 14,092        67,746
Staff and capital cost               29,955 32,441         32,512    32,512 50,861       178,281
Regional level activities            56,856 27,232         35,572    35,572 22,796       178,028
District level activities            30,662 95,668         111,294 111,271 139,350       488,245
Central level activities             21,901 20,048         20,503    20,548 26,978       109,978
Other                                82,018   6,912         12,598   12,598 22,417       136,543
TOTAL                               261,347 229,273        267,248 267,270 309,554      1,334,692
Released amount                     259,103 205,755        260,267 260,267
Expenditure                         259,019 205,849        254,878 259,497     *
Expenditure% on total released         100%    100%            97.9%   99.7%
* expenditure not available
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                    Page 64



Annex 4e: Contribution of NORAD


NORAD funded the National Tuberculosis Programme through WHO between 2000 and 2001 to pay
for drugs.
In addition there was a need for microscopes, accessories and other equipment to expand the
microscopy network to all 75 districts.
Activity                                             Estimated cost 2000              Estimated cost 2001    Through
Purchase of anti tuberculosis
medicines (rifampicin, ethambutol, and
streptomycin)                                                 279,680                        279,680         IUATLD
IUATLD administrative cost (8%)                               24,320                         24,320          IUATLD
Procurement of diagnostic supplies and
other equipment                                               66,120                                              WHO
Foil wrapping and boxing of anti-
tuberculosis medicines                                                                       66,120               WHO
WHO project support cost                                       9,880                          9,880
TOTAL                                                         380,000                        380,000




Annex 4f: Contribution of DfID


DFID finance to NTP                        2001          2002         2003          2004       2005      Total
                                          (£,000)       (£,000)      (£,000)       (£,000)    (£,000)   (£,000)
Drugs                                       574           629          686           742        801      3432
WHO PSC (6%)                                 34            38           41            45         48       206
Sub total + PSC                             608           667          727           787        849      3638
INF/TLP programme costs                     396           199          208           221        236      1260
WHO technical Assistance                    104           104          104            0          0        312
Sub total                                   500           303          312           221        236      1572
WHO (PSC 13%)                                65            40           41            29         31       206
Subtotal +PCS                               565           343          353           250        267      1778
Grand total                                1173          1010         1080          1037       1116      5416
Annex 4g: Contribution of WHO

WHO support to NTP, Nepal
Products                                                                   Regular budget (US$)
                                                1996     1997     1998       1999       2000      2001      2002     2003
Technical and administrative support               -        -     1,500      1,500      2,000     2,000    27,000   27,000
Surveillance of drug resistance                    -        -     8,000         -      13,000
Surveillance of HIV in patients with TB            -     7,700    8,000      2,500      9,000      9,000
National awareness and commitment for
TB control                                     47,575      750     5,000     2,000     13,000      2,000    6,000    3,000
Capacity of NTP managers for planning,
implementing, monitoring and evaluating
an effective TB control programme based
on DOTS strategy enhanced                          -        -     20,500     6,000      8,500     13,500    5,000    5,000
Technical training for aspects of TB
diagnosis and treatment                        63,000     5,000   22,400    22,400     26,000     10,000   10,000   10,000
Logistic support to the programme                  -         -                                             11,000    2,000
Coordinated TB control programme for
the Kathmandu Valley                           22,550     1,750
A five year strategic plan for TB control in
Nepal for the period of 2000-2004                                            8,000
Total                                          133,125   15,200   65,400    42,400     71,500     36,500   59,000   47,000
       Annex 4h: Epidemiological assumptions of NTP 5-year plan
       1998-2003


Epidemiological Assumptions

Population 1991:                       18,491,097
Population growth rate:                     2.60%
ARI in 1991:                               -2.10%
Annual change in ARI:                      -2.00%


Year                                   1998/1999         1999/2000         2000/2001   2001/2002   2002/2003
Population
                                      22,130,652 22,706,049 23,296,406 23,902,112 24,523,567
ARI                                        1.82%      1.79%      1.75%      1.72%     1.68%

Assumptions                                                          Median Estimates
Well Treated Proportion                    30%               40%          55%            60%         65%
Poorly Treated Proportion                  50%               40%          30%            25%         20%
Untreated proportion                       20%               20%          15%            15%         15%
Mortality in P+ Well Treated               5%                5%            5%            5%          5%
Mortality in P+ Poorly                     20%               20%          20%            20%         20%
Treated
Mortality in P+ Untreated                  70%               70%               70%       70%         70%
Mortality in P-/EP Well                    5%                5%                5%        5%          5%
Treated
Mortality in P-/EP Poorly                  15%               15%               15%       15%         15%
Treated
Mortality in P-/EP Untreated               20%               20%               20%       20%         20%
Prevalence to Incidence ratio               2                 1.9               1.8       1.7         1.5
ARI to incidence/100,000                    49                49                49        49          49
ratio
Ratio of P-/EP to P+ cases                 1.22              1.22              1.22      1.22        1.22

Note: The impact of HIV is assumed to be low during this period
       Source: Tuberculosis Control in Nepal 2055-2060 (1998-2003), Long Term Plan
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                                                                                                                                                                                  Page 68



Annex 4i: TB Case notification in Nepal 1972-2002




                                                                       Case Notifications 1972-2002
   15000

   14000

   13000

   12000
                                                             New P+
   11000

   10000                                                     New P-ve
    9000

    8000                                                     EP
    7000

    6000

    5000

    4000

    3000

    2000

    1000

       0
           1972/73

                     1973/74

                               1974/75

                                         1975/76

                                                   1976/77

                                                             1977/78

                                                                       1978/79

                                                                                 1979/80
                                                                                           1980/81

                                                                                                     1981/82

                                                                                                               1982/83

                                                                                                                         1983/84

                                                                                                                                   1984/85

                                                                                                                                             1985/86

                                                                                                                                                       1986/87

                                                                                                                                                                 1987/88

                                                                                                                                                                           1988/89

                                                                                                                                                                                     1989/90

                                                                                                                                                                                               1990/91

                                                                                                                                                                                                         1991/92

                                                                                                                                                                                                                   1992/93

                                                                                                                                                                                                                             1993/94

                                                                                                                                                                                                                                       1994/95
                                                                                                                                                                                                                                                 1995/96

                                                                                                                                                                                                                                                           1996/97

                                                                                                                                                                                                                                                                     1997/98

                                                                                                                                                                                                                                                                               1998/99

                                                                                                                                                                                                                                                                                         1999/00

                                                                                                                                                                                                                                                                                                   2000/01

                                                                                                                                                                                                                                                                                                             2001/02
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002                    Page 69


Annex 5: List of key people interviewed


Name                                Designation               Organisation
Allaby, Martin (Dr)                 Public Health Specialist  YUHP, UMN Nepal
Bam, Dirgh Singh (Dr)               Director                  National Tuberculosis Centre
Baral, JP (Dr)                      Director                  Leprosy Control Devision
                                                              Health Sector Reform, Programme preparation
Bista, Krishna Prasad               Co-ordinator
                                                              team
Chherti, MK (Dr)                    Director                  RHD Central Region
Devkota, Uma Nath (Dr)              Programme Officer         GTZ Health Sector Support Programme
Dhakal, Ramji                       Deputy Programme Manager GTZ Health Sector Support Programme
Gautam, Jagadish                    Administrator             INF/TLP Nepalgunj
Gurung, Devi                        DTLA                      DHO Lalitpur
Gurung, Lekh Bahadur                Field Officer             INF/TLP Nepalgunj
Gyawali, Badri Nath                 Statistical Officer       NTC
Jaishi, Bishnu Prasad               RTLA                      Central Regional Health Directorate
Jha, Kashi Kanta (Dr)               Senior Chest Physician    NTC
Kasland, Olav                       Deputy Manager/Consultant Norwegian Lung and Heart Association
Kato, J (Dr)                        Expert                    JICA/CTLHP, Nepal
Malla, Pushpa (Dr)                  Senior Chest Physician    NTC
Mark, Rana Vijaya                   Managing Director         Hargan's Nursing Home
Nepal, Damodar                      Regional Supervisor       Central Region/NTC
Neupane, Bhisma                     Chief Accountant          NTC
O'Dwyer, Michael (Dr)               Senior Adviser            DFID, Nepal
Osuga, K (Dr)                       NTP reviewer (external)   Research Institute of Tuberculosis, Japan
Overberg, K (Dr)                    NTP reviewer (external)   Norwegian Lung and Heart Association
Pande, Shanta Bahadur
                                    Senior Researcher                       Nuffield Institute for Health/NTP, Nepal
(Dr)
Preston, Christine                  Director                                YUHP, UMN Nepal
Rahaman, Md. Mojibur (Dr)           Epidemiologist                          SAARC TB Centre
Rana, Tirtha (Dr)                   Health Sector Specialist                World Bank, Nepal country office
Sharma, D N                         Trainer                                 Britain Nepal Medical Trust
Weakliam, David (Dr)                Director of Health Service              UMN, Nepal
Yoshiyama, T (Dr)                   Chief Advisor                           JICA/CTLHP, Nepal
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 70



Annex 6: List of background materials examined

1. A Comprehensive Report on JICA TB Control Project, Phase II (5th July 1994 – 4th
     July 2000), JICA TB Control Nepal
2. Ala Alwan & Peter Hornby ‘The implications of health sector reform for human
     resources development’ Bulletin of the World Health Organisation 2002,80(1)
3. Annual Report Department of Health Services 2057/58 (2000/2001)
4. Annual Report Tuberculosis Control Programme Nepal 2057/58 (2000-2001)
5. Annual Report, Department of Health Services 2052/53 (1995/96)
6. Annual Report, Department of Health Services 2053/54 (1996/97)
7. Annual Report, Department of Health Services 2054/55 (1997/98)
8. Annual Report, Department of Health Services 2055/56 (1998/99)
9. Annual Report, Department of Health Services 2056/57 (1999/2000)
10. Annual Report, Department of Health Services 2057/58 (2000/2001)
11. Anti- tuberculosis treatment in private pharmacies, Kathmandu Valley, Nepal
     IUATLD 4(8):730-736 , 2000 March
12. Esperanza C. Martínez, Hari Koirala ‘Primary Health Care Services in Nepal’ Field
     Report October 2002
13. Health Sector Strategy Development – An Agenda For Change, HMG MoH, August
     2002
14. Institutional Assessment of the Nepal Health Sector, Term of Reference
15. Medium Term Expenditure Programme (MTEP) to Operationalize 1st Three Years of
     10th Five Year Plan’s Health Programmes, Ministry of Health, Nepal January 2002
16. Medium Term Strategic Health Plan, Department of Health Services, MoH, February
     2001
17. Nepal Demographic and Health Survey 2001
18. Nepal Family Health Survey 1996
19. Nepal Operational Issues and Prioritisation of Resources in the Health Sector, June
     2000, Health Nutrition and Population Unit, South Asia Region – Document of the
     World Bank, Report No. 19613
20. Population Census 2001- National Report, HMG, Central Bureau of Statistics, June
     2002
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002   Page 71


21. Project Memorandum – Support to the NTP Nepal 2001-2006: WHO-DFID Nepal
22. Strategic Analysis to operationalize Second Long Term Health Plan, Nepal (Vol. 1)
23. TB control Network (TBCN) Draft Procedures and Functions Document
24. Tenth Five Year Health Plan (Draft), HMG MoH, 2002
25. The minutes of discussions between the Japanese management Consultant Team and
     the authorities concerned of HMG, Nepal on the JICA/CTLHP
26. Tuberculosis Control in Nepal 2055-2060 (1998-2003) Long Term Plan, NTP MOH,
     HMG, Nepal
27. Tuberculosis Control Programmes and the Impact on Health System and Service
     Development, A systematic review of three countries, Country case study protocol-
     Centre for Health and Social Development
Case Study of the National Tuberculosis Programme Implementation in Nepal: November 2002       Page 72



Annex 7: List of external peer reviewers

               Reviewer                                                             Position
1. Dr Ian Smith                                         WHO, Geneva
2. Dr Tirtha Rana                                       World Bank, Nepal
3. Dr Diana Weil                                        World Bank, Washington
4. Dr Christian Gunnerberg                              WHO, Nepal
5. Dr SB Pande                                          NTC
6. Dr Pushpa Malla                                      NTC
7. Dr K.J. Jha                                          NTC
8. Mr Tony Bondurant                                    DfID, Nepal