Collaborative public–private initiatives targeting multidrug-resistant tuberculosis (MDR-TB) supported by the Lilly MDR-TB Partnership: experiences in 2012–2016

Figures & data

Table 1 Characteristics of the projects discussed in the current report

	China	India	Russia	South Africa
Scope of work	• Support health care-capacity building • Standardize, train, and mentor professionals • Create Centers of Excellence to support the role of the China Center for Disease Control and Prevention and the China Medical Association as the ongoing health-system reform in China transitions TB prevention, control, diagnosis, and treatment • In Qinghai, a separate project with the provincial Qinghai Center for Disease Control and Prevention has also included a component of community awareness and engagement, in addition to training • The project with IFRC focused on improving patient outcomes for treatment of TB and MDR-TB through providing support (food, transport, education, etc)	• Engage private practitioners (pharmacists, doctors, practitioners not fully qualified, and rural health care providers) in early detection, referral, and treatment support	• Rapid diagnosis to reduce in-hospital transmission • Improve access to high-quality MDR-TB care • Train health care providers and researchers • Reach at-risk populations in prisons and migrant populations	• Evaluate the effectiveness of decentralized models of care
Partner organizations	• Chinese Medical Association Tuberculosis Society • Qinghai Provincial Center for Disease Control and Prevention • International Council of Nurses • Chinese Nurses Association • International Federation of Red Cross and Red Crescent Societies • London School of Hygiene and Tropical Medicine (LSHTM)	• CARE India • Indian Pharmaceutical Association • International Union Against Tuberculosis and Lung Disease of Southeast Asia (the Union) • Resource Group for Education and Advocacy for Community Health • St Stephen’s Hospital • TB Alert, India • World Health Organization	• Central TB Research Institute and other TB research institutes • Children in Need charity foundation • Federal correctional services • International Council of Nurses, Russian Nurses Association • International Federation of Red Cross and Red Crescent Societies • International Investment Center • Partners in Health, Brigham and Women’s Hospital, and Harvard Medical School • Russian regional TB services • Russian TB Society • Russian Union of Journalists	• Democratic Nursing Organisation of South Africa • Donald Woods Foundation • Eastern Cape Department of Health • FHI 360 • King Dinuzulu Hospital Complex • National Department of Health, South Africa • South African Medical Research Council • South African Red Cross Society, KwaZulu-Natal Chapter
Rationale for inclusion in Lilly MDR-TB Partnership	• Local expertise available • Established, credible implementing partner organizations, with local presence • Potential for initiatives to be adapted, replicated, and scaled up • Insufficient local funding • Measurable outcomes • Alignment with governmental objectives • Assurance that the impact of training programs would be measured (LSHTM)	• Local expertise available • Established, credible implementing partner organizations, with local presence • Potential for initiatives to be adapted, replicated, and scaled up • Measurable outcomes • Potential for Lilly Foundation engagement and support to add value • Local need for financial and logistical support • Alignment with governmental objectives	• Local expertise available • Established, credible implementing partner organizations, with local presence • Potential for initiatives to be adapted, replicated, and scaled up • Insufficient local funding • Measurable outcomes • Alignment with governmental objectives	• Local expertise available • Established, credible implementing partner organizations, with local presence • Potential for initiatives to be adapted, replicated, and scaled up • Existing local organizations that would benefit from management, coordination and financial support • Measurable outcomes • Alignment with governmental objectives
Role of Lilly Foundation	• Financial support • Communication expertise • Planning and execution advice • Support with meeting presentations	• Planning and technical advice • Financial support • Logistics support • Communication expertise • Analysis tools • Support with meeting presentations • Advocacy support	• Financial support • Communication expertise • Analysis tools • Advocacy support	• Financial support • Logistics support • Communication expertise • Analysis tools • Support with meeting presentations • Advocacy support
Role of Lilly Foundation across programs	Supporting sharing of best practices between partners and countries
	Supporting partners to help raise awareness of the work in the TB world (nationally and internationally)
Role of local organizations	• Execution • Presentation of results • Advocacy	• Joint planning • Field execution • Presentation of results • Advocacy	• Execution • Presentation of results • Advocacy	• Joint planning • Field execution • Presentation of results • Advocacy
Activities	• Training for Transformation initiative together with the International Council of Nurses (ICN) • Support nurses attendance of CMA annual academic conferences under the umbrella of the Lilly MDR-TB Partnership China program, with the support of the ICN, the China Nursing Association, and the CMA TB Society • Development of training curriculum and materials • Training sessions across China • Development of an online platform for remote consultation and mentoring • Establishment of 6 Centers of Excellence in the CDC system, and 6 centers of excellence by the CMA	• Baseline assessment of pharmacists’ knowledge, attitudes, and current approaches to people with TB symptoms • Training workshops with pharmacists using a structured training module • Regular follow-up visits to pharmacists • Courses for private physicians • Public–private centers for TB care • Home-based care for people with MDR-TB • Direct support for people with MDR-TB at facilities • Rural health care-provider training and support	• Implementation of the FAST intensified administrative approach to TB transmission control at hospitals in Voronezh Oblast and Petrozavodsk (Karelia) • Rapid molecular sputum tests (XpertW MTB/RIF) to diagnose infection • Establishing “proof of concept” to show better outcomes and reduced risk of spreading MDR-TB by separating individuals who may have MDR-TB from other patients while waiting for the test results • Initiating MDR-TB treatment early • Training for transformation for nurses	• Operational research on different models of care • Patient support at the community, primary-care, and institutional levels • Technical advice on decentralization of care • Awareness and education on TB symptoms in prisons, schools, and community settings, such as taxi ranks • Training for transformation for nurses
Performance measurements	• Survey of 19 randomly selected nurses • Nurse behavioral changes • Improvements in hospital conditions, sputum-collection, and transport procedures • Improvements in sputum-sample quality • Nurse provision of training to health care workers • Evaluation of education and training impact (ongoing)	• Referrals for TB testing, quality of referrals, and ensuring treatment adherence, where possible • Interviews with patients to evaluate satisfaction with pharmacists • “Pre–post” tests on knowledge and practices for private physicians • Treatment-completion rates for home-based care and short-course directly observed treatment-based support, as well as facility-based care	• Number of tests within 2 days of hospitalization • Number of positive MDR-TB tests • Number of patients assigned to a second-line drug regimen within 3 working days of the test	• Costs were analyzed for the year 2012 in terms of costs per treated patient and costs per successfully treated patient • Decreased loss to follow-up while undergoing MDR-TB treatment in the community • Number of patients treated for TB in prisons • Number of prisoners, schools, and community settings that have increased awareness of TB symptoms • Nurse provision of training to health care workers

Abbreviations: CMA, China Medical Association; FAST, Find cases Actively, Separate safely, Treat effectively; IFRC, International Federation of Red Cross and Red Crescent; MDR-TB, multidrug-resistant tuberculosis.

Table 2 Referral rates and percentages of people referred testing positive for tuberculosis (TB) after the training of pharmacists in different parts of India, 2013–2015

Location/NGO partner	Trained pharmacists, n	Referring pharmacists, n (%)	Referred people, n	Tested for TB, n (%)	Tested positive, n (%)
Telangana/TB Alert India	1,329	745 (56.1%)	3,263	2,940 (90.1%)	329 (11.2%)
West Bengal/CARE India	510	275 (53.9%)	808	600 (74.3%)	94 (15.7%)
Tamil Nadu/Resource Group for Education and Advocacy for Community Health	1,143	552 (48.3%)	1,169	950 (81.3%)	430 (45.3%)
Maharashtra/Indian Pharmaceutical Association	1,408	652 (46.3%)	446	400 (89.7%)	167 (41.8%)

Abbreviation: NGO, non governmental organization.

Table 3 Number of patients with MDR-TB identified and put on appropriate treatment regimens within 3 working days using FAST in hospitals in Voronezh and Petrozavodsk, respectively

Location	Patients admitted with suspected pulmonary TB	Patients tested within 2 days of admission, n (%)	Positive test results, n (%)	Rifampicin-resistant strains, n (%)	Patients assigned line treatment within 3 working days of test, n (%)
Voronezh	932	863 (93.5%)	407 (47.2%)	161 (39.6%)	159 (98.8%)
Petrozavodsk	1,174	1,084 (92.3%)	509 (47%)	209 (41.1%)	200 (95.7%*)

Notes:

* Seven patients did not enroll; 99% of enrolled patients were assigned treatment within 3 working days. Data from Barrera et al.¹⁵

Abbreviations: MDR-TB, multidrug-resistant tuberculosis; FAST, Find cases Actively, Separate safely and Treat effectively.

Table 4 Cost-effectiveness of different care models for people with MDR-TB in KwaZulu-Natal province, South Africa, in 2012²⁰

Care model	Total cost per patient treated (US$)	Cost per patient successfully treated (US$)
Decentralized 2	33,554	64,776
Centralized hospital	30,067	55,680
Decentralized 1	24,516	34,050
Community-based: mobile	10,616	18,495
Community-based: clinic	9,519	15,865

Note: Reproduced from Loveday M. Cost-effectivess of different models of care for MDR-TB patients in South Africa. Presented at: the 68th session of the World Health Assembly; May 20th, 2015; Geneva, Switzerland.²⁵

Abbreviation: MDR-TB, multidrug-resistant tuberculosis.

BarreraELivchitsVNardellEF-A-S-T: a refocused, intensified, administrative tuberculosis transmission control strategyInt J Tuberc Lung Dis20151938138425859991

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LovedayMPadayatchiNWallengrenKAssociation between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmesPloS One20149e9401624718306

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LovedayMCost-effectivess of different models of care for MDR-TB patients in South AfricaPresented at: the 68th session of the World Health AssemblyMay 20th, 2015Geneva, Switzerland

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