National tuberculosis programme policy and manual

Objectives

Lesotho’s National Tuberculosis Programme seeks to reduce tuberculosis mortality, morbidity and transmission until tuberculosis no longer constitutes a public-health problem, while preventing drug resistance.[1]It adopts the New Stop TB Strategy as the national framework, retaining directly observed treatment, short-course as its core delivery strategy and aiming to provide patient-centred, high-quality care for all people with tuberculosis.[2]

• Achieve universal access to quality diagnosis and patient-centred treatment, reduce the social and economic burden of tuberculosis, protect poor and vulnerable populations, and support development and use of improved tools.[3]
• Expand and sustain high-quality directly observed treatment, short-course services, address tuberculosis and HIV co-infection, multidrug-resistant tuberculosis, extensively drug-resistant tuberculosis and high-risk groups, and contribute to health-system strengthening.[2]
• Detect at least 70% of estimated sputum smear-positive cases and cure at least 85% of newly detected sputum smear-positive cases, in line with global targets adopted by the programme.[4]
• Reduce tuberculosis prevalence and deaths by 50% from 1990 levels by 2015, reverse incidence, and pursue eventual elimination of tuberculosis as a public-health problem.[3]
• Strengthen childhood tuberculosis prevention, diagnosis and treatment, including contact investigation, preventive therapy for eligible contacts, and special attention to children living with HIV or at risk of severe disease.[5][6][7]
• Improve tuberculosis and HIV collaboration by reducing tuberculosis among people living with HIV and reducing HIV-related morbidity among tuberculosis patients through testing, prevention, cotrimoxazole prophylaxis, care, support and antiretroviral therapy.[8][9]
• Maintain quality-assured laboratory services close to communities to support diagnosis, treatment decisions, follow-up, cure of infectious cases, interruption of transmission and surveillance of drug susceptibility.[10]
• Prevent transmission in health-care settings, congregate settings and prisons through infection control, prompt diagnosis, effective treatment and integration of prison and civilian tuberculosis services.[11]
• Mobilise political commitment, resources, communities and partners through advocacy, communication and social mobilisation to improve case detection, treatment adherence, stigma reduction and accountability.[12][13]

Implementation

Implementation is embedded in the primary health-care system, with districts as the principal management units. District Health Management Teams organise services through District Tuberculosis Coordinators, while the National Tuberculosis Programme operates in the Ministry of Health Disease Control Unit under the Disease Control Division, Primary Health Care Directorate and Director-General of Health Services.[1]The approach combines standardised treatment and laboratory quality assurance with decentralised supervision, community participation, public-private collaboration, reliable supplies, recording and reporting.[14][2][15]

• Maintain a strong central programme unit, develop and implement a medium-term strategic plan, update treatment guidance using evidence and World Health Organization-endorsed practice, and organise tuberculosis treatment within primary health care.[15]
• Deliver diagnosis through a tiered laboratory network of peripheral district, intermediate and central national laboratories, with the Queen Elizabeth II Hospital laboratory responsible for reference functions including culture, drug-susceptibility testing, quality assurance, training and surveillance.[16]
• Provide supervised, standardised treatment with uninterrupted quality-assured medicine supplies, patient-centred support, counselling, adherence tracing and free anti-tuberculosis medicines and sputum smear examinations.[14][17]
• Strengthen national and district structures, ensure country-wide access to diagnostic and treatment services, and use facility, hospital, community and directly observed treatment supporters to sustain care and follow-up.[18][1]
• Refer multidrug-resistant tuberculosis cases to the specialised unit at Botshabelo Hospital for assessment and treatment decisions, while arranging ongoing treatment through designated districts and clinics and considering community-based care where feasible.[19]
• Establish functional tuberculosis and HIV coordination through a joint working group involving the tuberculosis and AIDS programmes, district teams, communities of people living with HIV, stakeholders and health partners.[8]
• Integrate tuberculosis and HIV interventions across community, primary-care and secondary-care services, involving government, mission, private, faith-based, non-governmental and community-based providers.[9]
• Require health-care settings to maintain written tuberculosis infection-control plans, designate infection-control officers, undertake periodic transmission-risk assessments, improve ventilation and apply respiratory protection in specialised high-risk settings.[11]
• Use patient-level registers, laboratory forms, treatment cards, referral forms, district reports and quarterly and annual reporting to track case finding, sputum conversion, treatment cohorts, medicine returns, supply needs and programme performance.[20][21]
• Conduct supportive, task-oriented supervision from the central programme to districts and from districts to facilities, review prior corrective actions, use standard supervision tools and include planned visits in the annual programme budget.[22]
• Engage the World Health Organization as the principal technical partner, alongside United Nations agencies, international organisations, non-governmental organisations, the Christian Health Association of Lesotho, private providers and communities.[1][23]
• Build workforce capacity through a needs-based Human Resource Development plan, in-service training and training evaluation involving central and district staff, managers, private providers, mission-sector personnel and professional associations.[24][12]

Monitoring & Evaluation

The monitoring and evaluation framework combines routine case registration, laboratory quality assurance, treatment-cohort monitoring, TB/HIV reporting, supervision and periodic programme evaluation. It uses patient-level records and district-to-national information flows to assess case detection, treatment outcomes, supplies, service quality and progress towards epidemiological objectives.[1][20][21]

• Monitor core programme performance against targets for detecting 70% of estimated smear-positive cases and curing at least 85% of newly detected smear-positive cases.[4]Historical results included a 71% case-detection rate and 73% treatment success among the 2005 cohort.[2]
• Track impact through tuberculosis prevalence, incidence and mortality, with stated baselines of 544, 696 and 107 respectively, alongside global targets to halve prevalence and mortality by 2015 relative to 1990.[22]
• Measure operational coverage through district coverage, population access, health-facility provision, smear conversion and the proportion of identified infectious cases that are smear-positive.[25]
• Record individual cases, treatment history, disease classification, laboratory results and final outcomes in tuberculosis registers.[26][5][27]Standard treatment outcomes are cure, treatment completed, failure, death, default and transfer out.[5]
• Conduct scheduled sputum-smear follow-up for smear-positive patients during Category I and Category II treatment, and use culture and drug-susceptibility testing when treatment failure or multidrug-resistant tuberculosis is suspected.[28][29]
• Report HIV test results in patient records and tuberculosis registers, and submit them quarterly with treatment-outcome data.[9]
• Maintain daily facility and laboratory recording, weekly or monthly district registers, and quarterly and annual reports covering case finding, sputum conversion, treatment cohorts and tuberculosis-drug returns.[20][21]
• Evaluate the programme at the end of each plan period against all programme indicators, operational targets and epidemiological objectives.[20]Conduct periodic programme monitoring with partners, preferably annually or at the mid-term of the Medium Term Plan.[22]
• Strengthen laboratory accountability through internal quality control, external quality assessment, continuous quality improvement, supervisory checklists, panel testing and blinded slide rechecking.[16][30][31]Supervisory reports are issued to higher authority and relevant hospital and laboratory leads within one week, with follow-up of recommendations.[32]
• Monitor training quantity, quality and service-delivery effects through staff-training targets, pre- and post-course tests, supervision and facility-level capacity indicators.[12]
• Track private-sector participation through notification, directly observed treatment implementation and treatment-outcome reporting by private hospitals, clinics and doctors working under Ministry of Health agreements.[33]

Several extracts refer to surveillance, including drug-susceptibility surveillance, tuberculosis prevalence surveys, planned drug-resistance surveys and joint tuberculosis/HIV surveillance.[14][2][10][8]However, the supplied material does not provide a single consolidated national indicator matrix, complete reporting calendar, data-quality audit framework or fully specified accountability architecture.

Costing & Financing

Financing is presented principally as a requirement for sustained political commitment, nationwide service delivery, medicines and laboratory supplies, supervision, training, advocacy and partnership mobilisation. The material identifies government and external support but does not provide a consolidated costed plan, expenditure framework, quantified funding gap or economic assumptions.[14][2][15]

• Maintain government funding for the National Tuberculosis Programme, which has reportedly been fully funded by the Government of Lesotho since 2001.[1]The Government also increased allocations to support country-wide access to quality tuberculosis services.[18]
• Use two Global Fund to Fight AIDS, Tuberculosis and Malaria grants to support rapid expansion of tuberculosis diagnostic and treatment services.[18]
• Provide anti-tuberculosis medicines and sputum-smear examinations free of charge, while seeking to reduce patients’ time and travel costs in accessing treatment.[17]
• Plan procurement from expected caseloads and standard regimens, allowing at least six months’ lead time, annual requirements, reserve stock and quarterly distribution according to need.[21]
• Include planned supervisory visits in the annual programme budget, although no allocation is specified.[22]
• Estimate training costs for participant and facilitator per diems and travel, printed materials, stationery and refreshments.[24]
• Allocate regular budget funding to advocacy, investigate prospective donors and seek political and financial support from corporations, professional associations and workers’ unions.[34][33]
• Recognise operational resource requirements without assigned monetary values, including laboratory reagents and consumables, microscopy equipment, patient drug kits, reserve medicines, infection-control measures, paid treatment supporters, food-support links and point-of-care diagnostic equipment.[35][36][37][38]

The material characterises multidrug-resistant tuberculosis treatment as difficult and expensive, but gives no numerical treatment costs.[39]It also notes that culture is expensive and slow, limiting routine use under programme conditions.[40]No grant values, currency-denominated allocations, unit costs, financing projections, funding-gap estimates or cost-effectiveness assumptions are specified.[18][41][42]