The Islamic Republic of Pakistan

****
National Strategic Plan for Tuberculosis
Control, 2020-2023
List of contents
Executive summary ................................................................................................................................. 1
The Plan’s goals and key strategies................................................................................................. 3
1. Introduction .................................................................................................................................... 5
1.1 What this NSP is ...................................................................................................................... 5
1.2 Results of the Pakistan Joint TB Program Review Mission (JPRM) 2019 ................................ 5
1.3 The NSP 2017-2020 ................................................................................................................. 7
1.3.1 Vision, goal, target and objectives .................................................................................. 7
1.3.2 Strategic directions ......................................................................................................... 8
1.3.3 What was achieved (and not achieved) ........................................................................ 10
1.4 Process of development of this NSP ..................................................................................... 11
2. Background ................................................................................................................................... 12
2.1 Global TB context .................................................................................................................. 12
2.1.1 Global epidemiology of TB ................................................................................................... 12
2.1.2 Global political response ...................................................................................................... 13
2.1.3 Global achievements against the targets...................................................................... 13
2.2 National context.......................................................................................................................... 14
2.2.1 Geography ..................................................................................................................... 14
2.2.2 Population ..................................................................................................................... 14
2.2.3 Politics ........................................................................................................................... 16
2.2.4 Socio-economic development ...................................................................................... 16
2.2.5 Health expenditure ....................................................................................................... 17
2.2.4 National health structure .............................................................................................. 18
2.2.5 Health performance ...................................................................................................... 20
2.2.6 Health priorities, policies, strategies and regulatory frameworks................................ 21
2.2.7 Social protection for health .......................................................................................... 23
2.3 National tuberculosis situation ............................................................................................. 24

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 2.3.1 Organisation and management of TB services ............................................................. 24
2.3.2 Current epidemiological status ..................................................................................... 32
2.3.3 TB Programme Funding................................................................................................. 36
2.4 TB service components ......................................................................................................... 39
2.4.1 Case identification and diagnosis - drug susceptible TB ............................................... 39
2.4.2 Programmatic Management of Drug Resistant TB (PMDT) .......................................... 41
2.4.3 Laboratory network ...................................................................................................... 42
2.4.4 Engaging all care providers - Public-Private Mix (PPM) ................................................ 44
2.4.5 TB in children ................................................................................................................ 47
2.4.6 TB/HIV and other comorbidities ................................................................................... 49
2.4.7 Research/Innovation ..................................................................................................... 50
3. Gap analysis .................................................................................................................................. 52
4. Vision, mission and goals .............................................................................................................. 54
Vision of the NSP 2020-2023 ............................................................................................................ 54
Mission .............................................................................................................................................. 54
Goal, impact and targets ................................................................................................................... 54
Summary plans of Provinces, Regions and Territories ..................................................................... 55
5. Summary of provincial, regional and territorial objectives .......................................................... 67
5.1 Political commitment ....................................................................................................... 67
5.2 Increasing case finding (DS-TB) ........................................................................................ 67
5.3 Management of drug resistant TB (PMDT) ....................................................................... 68
5.4 Childhood TB ..................................................................................................................... 68
5.5 Support to the laboratory network................................................................................... 69
5.6 Accelerated implementation of TB/HIV collaborative activities and other comorbidities
69
5.7 Operational research and innovation ............................................................................... 69
5.8 Quitting smoking ............................................................................................................... 70
6. Central functions .......................................................................................................................... 70
7. Prioritisation approaches ............................................................................................................. 76
8. Modelling results of achievements with proposed inputs .......................................................... 77
8.1 Overview of the TIME model ................................................................................................ 77
8.2 Model calibration.................................................................................................................. 77
8.3 Model scenarios .................................................................................................................... 78
9. The Monitoring and Evaluation Plan ............................................................................................. 81
1 Introduction ............................................................................................................................. 81
2 Description (summary) of the information system for TB....................................................... 81

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 2.1 The Health Information context ....................................................................................... 81
2.2 Monitoring and Evaluation for TB ..................................................................................... 81
2.3 Strengths (derived from the JPRM)................................................................................... 82
2.4 Weaknesses....................................................................................................................... 82
2.5 JPRM Recommendations relevant to this NSP.................................................................. 83
2.6 Moving ahead ................................................................................................................... 84
3. Targets and indicators for the NSP ........................................................................................... 84
4. Surveys planned for 2020 – 23 ................................................................................................. 91
10. Operational Plan ........................................................................................................................ 92
11. Technical assistance (TA) plan .................................................................................................... 93
1. Introduction .............................................................................................................................. 93
2. Areas indicated for TA by the JPRM .......................................................................................... 93
3. Areas for TA indicated in the provincial/regional plans ........................................................... 94
4. Recommendations for finalising TA needs ............................................................................... 94
12. Contingency Plan for Emergencies, Natural Disasters etc. ........................................................ 96
Background ....................................................................................................................................... 96

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Acknowledgements
Ministry of National Health Services, Regulations & Coordination, acknowledges the support
of international and national stakeholders in the development of NSP . We would like especially
thank World Health Organization, The Global Fund, the CCM Pakistan, TB experts from National,
Provincial & Regional TB Control Programs, The Indus Hospital, Mercy Corps and all implementing
partners for their lead role and active participation in preparation of NSP/PSPs documents.
NTP Pakistan duly acknowledges the contribution of consultants: Dr Paul Nuun, in the development
of NSP/PSP documents.
NSP PSP Focal Persons:

National TB Control program appreciates the role of focal persons for the development of NSP/PSPs

Dr. Muhammad Aamir Safdar- NTP Focal Person.

Dr. Hazoora Shaikh- PTP Sindh Focal Person.
Dr. Ahmad Wali-PTP Balochistan Focal person.
Dr. Abdul Raheem-PTP KP Focal Person.
Dr. Asif Sheikh-PTP Punjab Focal Person.
NATIONAL TEAM:

Dr. Aurangzaib Quadir, Dr. Sabira Tahseen, Dr. Syed Hussain Hadi, Dr. Abdul Ghafoor, Dr. Furqan
Ahmad, Dr. Zafar Iqbal Toor, Mr. Zaheer Ahmad, Mr. Tanveer Ahmad, Dr. Fakhra Naheed, Dr. Yasir
Waheed, Abdul Rehman, Mr. Ahmad Nadeem Mir, Mr. Abdullah latif, Mr. Naveed Chaudhary,
Obaidullah Baloch, Mr. Rizwan Anees

PROVINCIAL TEAM:

Baluchistan
Dr Sami Ullah Kakar, Dr. Ahmad Wali, Dr. Bashir Ahmed , Mr. Fareed Ahmad, Mr. Aftab Ayoub Jamali,
Mr. Abdul Samad, Mr. Ahmed Khan Tareen, Dr. Tariq Jafar, Dr. Shoaib Aziz Kurd Dr. Noor Qazi Dr. Ishaq
Panezai Dr. Khalid Qambrani Dr. Dawood Khan Achakzai Dr. Akhtar Muhammad Dr. Nasir Shiekh
Dr. Abdullah Sherani Dr. Tahira Kamal Dr. Shereen Khan Dr. Nauman Safdar, Dr. Salman Khan, Mr.
Khalid Kasi, Dr. Amina Rashid, Dr. Saeed Ullah Khan, Mr. Imdad Ali, Dr. Shazia Shaheen, Dr. Hayat
Ronjho, Dr. Aurangzaib Quadir, Dr. Muhammad Aamir Safdar, Dr. Abdul Ghafoor, Dr. Hussain Hadi, Dr.
Sabira Tahseen, Dr. Furqan Ahmed, Dr. Khawaja Laeeq Ahmad, Dr. Babar Alam, Mr. Beberg Mengal,
Dr. Farooq Azam Jan, Dr. Ejaz Qadeer, Mr. Watan Yar Khilji
Provincial Consultant:
Dr Lubna Khalil Saddiqui

Khyber Pakhtunkhwa
Dr Qasim Abbass, Dr. Abdul Khalique, Dr. Faisal Seraj, Dr. Muhammad Dost Khan, Dr. Sabir Rehman,
Dr. Maqsood Bangash, Mr. Khair-ul-Bashar, Mr. Jamil Durrani, Dr Khawaja Laeeq Ahmad, Dr.
Aurangzaib Quadir, Dr. Hussain Hadi, Dr. Muhammad Aamir Safdar, Dr. Ghafoor, Dr. Zafar Toor, Dr.
Yasir Waheed, Dr. Sabira Tahseen, Dr Fakhra Naheed, Dr Furqan Ahmad
Consultant
Dr Aamir Rafique Khattak

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Punjab
Dr. Aamir Nazir, Dr. Muhammad Asif, Dr. Anzar Ahmad, Dr. Lala Rukh, Dr. Usman Rasool Lodhi, Mr.
Omair Shahid, Mr. Husnain Mehmood, Dr. Khawaja Laeeq, Dr. Jamshed, Dr. Irfan, Dr. Abdul Majeed,
Dr. Nauman Safdar, Dr. Farah, Dr. Farkhanda, Dr. Tariq, Dr. Ashraf Nizami, Dr. Mian Tariq Mehmood,
Dr. Khalid Waheed, Dr. Iqbal Bano, Dr. Aurangzaib Quadir, Dr. Hussain Hadi, Dr. Muhammad Aamir
Safdar, Dr. Ghafoor, Dr. Zafar Toor, Dr. Yasir Waheed, Dr. Sabira Tahseen, Dr Fakhra Naheed
Consultant:
Dr Owais Gohar

Sindh
Dr. Hazoora Sheikh, Dr. Abdul Khalique Domki, Dr. Saleem Hasan Kazmi, Dr Shahid Butt, Dr Salman,
Falak Madhani, Mr. Samiullah, Dr. Srichand, Dr. Hassan Jalbani, Dr. Nadeem, Dr. Leela Ram
Dr. Aurangzaib Quadir, Dr. Hussain Hadi, Dr. Muhammad Aamir Safdar, Dr. Ghafoor, Dr. Zafar Toor,
Dr. Yasir Waheed, Dr. Sabira Tahseen, Dr Fakhra Naheed, Ms Aamna Rashid, Dr Tariq, Dr Bushra Jamil
Consultant
Dr. Javed Ahmad Shaikh

REGIONAL TEAMS:

AJK: Dr. Ch: Muhammad Asghar, Dr. Muhammad Aamir Safdar Dr. Abdul Ghafoor Dr. Hussain Hadi Dr.
Sabira Tahseen, Advisor NRL, Dr. Furqan Ahmed, Dr. Fakhra Naheed, Ms. Amina Rashid, Dr. Nauman
Safdar, Dr. Muhammad Tariq

FATA: Dr. Faisal Khanzada, Dr. Rauf Wazir, Mr. Wakeel Khan, Dr. Aurangzaib Quadir, Dr. Hussain Hadi,
Dr. Muhammad Aamir Safdar, Dr. Ghafoor, Dr. Zafar Toor, Dr. Yasir Waheed, Dr. Sabira Tahseen, Dr
Fakhra Naheed

GB: Dr. Shah Zaman, Dr. Hafeez Ullah, Dr. Aurangzaib Quadir, Dr. Hussain Hadi, Dr. Muhammad Aamir
Safdar, Dr. Ghafoor, Dr. Zafar Toor, Dr. Yasir Waheed, Dr. Sabira Tahseen, Dr Fakhra Naheed

ICT: Dr. Zulfiqar , Dr. Aurangzaib Quadir, Dr. Hussain Hadi, Dr. Muhammad Aamir Safdar, Dr. Ghafoor,
Dr. Zafar Toor, Dr. Yasir Waheed, Dr. Sabira Tahseen, Dr Fakhra Naheed, Ms Aamna Rashid,

Consultant
Dr Ashraf Bughti

PARTNERS:
CCM: Dr Sajid Ahmad
WHO: Dr Khawaja Laeeq Ahmad,
INDUS/ Green Star: Dr Nauman Safdar, Dr Khalid Farough, Dr Sobia Faisal, Ms Falak Madhani, Dr Shifa
Habib,
MERCY CORP: Dr Farah Noreen, Ms Aamna Rashid, Dr Tariq, Dr. Saeedullah Khan, Mr Imdad Ali
Bridge: Dr Sharaf Ali Shah, Dr Shahina Qayyum
ASD: Dr Akmal Naveed, Dr Abdul Latif
AKU: Dr Bushra Jamil

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List of abbreviations
aDSM active Drug Safety Monitoring and JPRM Joint TB Program Review Mission
Management KP Khyber – Pakhtunkhwa
ACD Association for community LHWs Lady (Community) Health
development Workers
ASD Association for social development LPA Line Probe Assay
AKUH Aga Khan University Hospital LTBI Latent TB Infection
ART Anti- Retroviral Therapy MC Mercy Corps
BC Bacteriologically Confirmed MDRTB Multi Drug Resistant TB
BHU Basic Health Units M&E Monitoring and Evaluation
BISP Benazir Income Support Program MNCH Maternal, Neonatal and Child
BMU Basic Management Unit Health
CAD4TB Computed Aided Diagnostics MoHs Ministries of Health (Provincial)
for TB
MoNHSRC Ministry of National Health
CHS Community Health Solutions
Services, Regulation and
CMU Common Management Unit
Coordination
CPT Co-trimoxazole Preventive
NCDs Non -Communicable Diseases
Therapy
NGO Non- Governmental Organization
CXR Chest X-ray
N/PTPs National and Provincial TB
DFID Department for International
Programs
Development (United Kingdom)
NTRL National Tuberculosis Reference
DHIS2 District Health Information System
Laboratory
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NTP National TB Program
DHQs District Headquarter Hospitals
OOP Out of Pocket
DOT Directly Observed Therapy
OPD Out Patient Department
DOTS Directly Observed Therapy –
PAS Para Amino Salicylic Acid
Short Course
PATA Pakistan Anti- TB Association
DR-TB Drug Resistant TB
PC Planning Commission
DST Drug Susceptibility Testing
PDHS Pakistan Demographic and Health
DS-TB Drug Susceptible TB
Survey
EPI Expanded Program of
PHC Primary Health Care
Immunization
PLHIV People Living with HIV
EPTB Extra Pulmonary TB
PMDT Programmatic Management of
EQA Externa Quality Assurance
Drug Resistant TB
FAST Find TB Actively, Separate Safely,
PPHI People Primary Health Care
Treat Effectively
Initiative
FATA Federal Administered Tribal Areas
PPD Purified protein derivative
FDCs Fixed Dose Combination Drugs
PPM Public Private Mix
FLDs First Line Drugs
PPs Private Providers
GB Gilgit Baltistan
PR Principal Recipient
GDP Gross Domestic Product
PSM Procurement and Supply Chain
GDF Global Drug Facility
Management
GLC Green Light Committee
PTPs Provincial TB Programs
GoP Government of Pakistan
PWIDs People Who Inject Drugs
GPs General Practitioners
RHC Rural Health Centre
GSM Greenstar Social Marketing
RR-TB Rifampicin Resistant TB
HIV Human Immunodeficiency Virus
Rs Pakistan Rupees
ICT Islamabad Capital Territory
SDGs Sustainable Development Goals
IHN Indus Health Network
SLDs Second Line Drugs
IPT Isoniazid Preventive Therapy

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SOPs Standard Operation Procedures
STR Short Treatment Regimen
TA Technical Assistance
TB Tuberculosis
THE Total Health Expenditure
THQs Tehsil Headquarter Hospitals
TB-NSP TB- National Strategic Plan
UNGA-TB-HLM United Nations General
Assembly TB High Level Meeting
TST Tuberculin Skin Test
TWG Technical Working Group
UHC Universal Health Coverage
USAID United States Agency for
International Development
VCT Voluntary Counseling and Testing
WB World Bank
WHO World Health Organization
XDRTB Extensively Drug Resistant TB

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The Core Plan
Executive summary
Through this National Strategic Plan (NSP), Pakistan aims, in the next four years, to treat successfully
1.6 million cases of tuberculosis (of which 200,000 are children), and an additional 35,000 cases of
multi-drug resistant TB, and provide 1.6 million courses of post-exposure (preventive) treatment
throughout the country, at a cost of US$ 621 million.

This is a full expression of Pakistan’s needs for 2020-2023 for controlling tuberculosis. It follows a
consultative, “bottom-up” process involving representatives of all stakeholders in each of the
provinces, regions and territories, which has been organised by the World Health Organization
(WHO) and the National TB Control Programme (NTP) between September and December 2019.
This NSP recognises the failure to achieve the targets set in the NSP, 2017-2020 and takes into
account the reasons for this. It has drawn substantially on the analyses that came out of the patient-
centred workshop on the epidemiology of TB in Pakistan in January, 2019, and the clear-sighted
recommendations of the Joint Pakistan Review Mission (JPRM) for TB in February, 2019.

The Burden
Pakistan has the world’s 5th highest number of people falling ill with TB each year - 562,000 in 2018.
Only India, Indonesia, China and the Philippines have more cases. While the Eastern Mediterranean
has only 8% of the global burden, Pakistan is responsible for 75% of it. However, only 369,000 cases
were notified in 2018, meaning that 193,000 – over one third - were not notified. This was especially
true of the elderly, and of men. These “missing cases” could have been diagnosed in the private
sector and perhaps treated there (but not notified), or they could have gone without treatment of
any kind, continuing to spread the disease to their families and loved ones.

While most large countries in Asia are seeing significant falls in incidence of TB, in Pakistan the
estimated TB incidence has been static for 20 years, which means that with Pakistan’s vigorous
population growth, the number of cases goes up every year.

WHO estimates that 44,000 Pakistani citizens died from TB in 2018, the highest number from any
infectious disease. Tuberculosis is the 7th largest cause of lost years of life in Pakistan, behind the
major causes of death in infants and children, and ischaemic heart disease.

In 2018 there were an estimated 28,000 multi-drug resistant (MDR-TB) cases, but only 11% were
diagnosed and put on treatment. The HIV epidemic is relatively small and concentrated in Pakistan.
Nevertheless, 3,800 patients with HIV-associated TB were estimated to have occurred in the same
year, yet only 636 were diagnosed, and of these only 417 received anti-retroviral treatment.

The proportion of new and relapse TB cases that are children (0-14 years) is within the expected
range of 5-15% (12.3% in 2017), but GB, KP and FATA had a very high proportion of childhood
notification in 2017 (41.2% and 29.7% and 28.4% respectively). In these areas, therefore, childhood
TB in all probability is being over-diagnosed.

Nationally, 61% of patients seek care in the formal private sector (Punjab 76%), 24%, in the informal
private sector (Balochistan 27%, KP 35% and Sindh 33%), and only 13% in the public sector. Yet only
5% of the national total of (private) general practitioners is engaged in TB control.

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The Achievements
From near zero in 2000, Pakistan was notifying over 150,000 cases of TB annually by 2007. A further
growth in notifications followed to a peak of over 360,000 in 2017. A detailed NSP for 2017-2020
was prepared. The NTP has treated more than 4 million people with quality assured drugs since its
revival while maintaining treatment success rates of more than 90% for many years.

The new rapid molecular diagnostic tests (MTB-RIF tests on the GeneXpert platform) have been
introduced and are now available throughout the country. The public sector has engaged several
private sector partners, notably the principal recipients of the Global Fund, Indus Health Network
(IHN) and Mercy Corps, and their sub-recipients, Greenstar Social Marketing, Community Health
Solutions (CHS), The Pakistan Lions Youth Council (PLYC), Association for Community Development
(ACD), the Association for Social Development (ASD), Bridge Consultants Foundation (BCF) and
others, who have introduced active case finding and other innovative approaches, and helped to
boost case finding, especially among the clients of private practitioners. The NTP has supported
provincial TB programmes in the development and implementation of the “Mandatory TB Case
Notification” bill which has been passed by three Provincial assemblies and by-laws developed.

The Challenges
The NSP 2017-2020 was never properly funded. As reported by the 2019 JPRM, the highest level
policy makers were – and are - generally unaware of the health and economic burden created by TB.
Domestic funding for TB has therefore never adequately materialised. The TB Free Initiative
announced by the President in April 2019 appears to have fizzled out through lack of national level
staff.

While over the past two decades there has been a huge increase in TB case finding, over one third of
cases is still not notified in Pakistan. This is because neither the public, nor the private, sector, is
fully mobilised to find all the cases presenting to them: of over 5,000 basic health units (BHUs) only
about 124 are fully, officially, engaged in TB control, that is they have both the resources to diagnose
and treat TB, or to refer the patient to a competent facility for diagnosis and care. With the
exception of a few pilot projects like those in Sindh, lady health workers (LHWs) are also not involved
in TB case finding or management, despite their major role in visiting families and communities. In
the private sector, only 5% of GPs are engaged with the local TB control programme, and yet they
are providing 23% of the patients notified.

A major bottleneck is the lack of a systematic mechanism to transport sputum specimens from each
primary health care (PHC) facility to the nearest diagnostic facility, usually a rural health centre
(RHC), where microscopy is available, or to transport the sputum to the nearest GeneXpert facility
for MTB-RIF testing. The GeneXpert machines are therefore under-utilised. Results take too long to
return to the clinical staff.

In practice, still today in Pakistan, diagnosis of TB largely depends on symptoms, followed by sputum
microscopy. Yet, the 2011 prevalence survey showed that only 61% of the diagnosed TB cases
screened positive on symptoms (cough >2wks) - other TB cases were detected by the finding of
abnormalities on chest X-ray. Furthermore, about one-third of cases of TB are sputum smear
negative, meaning that these patients, even if they had symptoms, would be missed by the routine
case detection that relies on microscopy only. This plan therefore aims for a significant increase in
the sensitivity of the diagnostic process through the inclusion of chest X-ray, where possible, as a
screening test, followed by an MTB-RIF test.

The lack of domestic engagement and financial support has also translated into a failure to
financially support a national level central unit. Such a unit, or Institute, is essential to provide

2
organisational and management support and strategic and technical policy guidance to the
provinces and regions, especially around the introduction of new techniques and approaches. It also
has a key role in advocating for domestic support for TB.

Historically, Pakistan has reserved preventive treatment (PT) for the under 5s, although even in that
group, implementation has been at a low level. WHO’s recommendations, since the UN High Level
Meeting on TB in 2018, now advocate PT for infected contacts of any age, which will require a
significant shift of thinking, policy and practice, that is starting in this NSP.

The Plan’s goals and key strategies

The vision of this NSP is a TB-free Pakistan with zero deaths, disease, and poverty caused by TB.
The mission is to effectively end the TB epidemic in Pakistan by 2035. The vision and mission are
unchanged from the previous NSP, however, the goal is to get back on track to end the TB epidemic
by 2030, and therefore this Plan aims to treat successfully at least 1.6 million cases of tuberculosis.
Multi-sectoral accountability is key to achieving these targets and is, for example, an important
element of the Islamabad Model Health City Initiative by the ICT authorities and the Ministry of
National Health Services, Regulations and Coordination (MoNHSR&C). To achieve these targets the
following strategies will be implemented, and assessed within the context of the multi-sectoral
accountability framework:

1. All four provinces and most of the territories and regions aim to ensure engagement of
almost all BHUs in the public sector in TB control. In Sindh, for example, this will be achieved
mainly through the PPHI, which has already been subcontracted by the provincial
government to manage BHUs, and which will train all their front-line clinicians, and provide
access for all BHUs to appropriate diagnostic facilities within the PPHI network. Elsewhere,
this includes provision for referral of any presumptive case to a diagnostic facility, and/or the
provision of a reliable, systematic mechanism for the transport of sputum specimens (see
later). Many provinces, with the exception of Balochistan (where this has already been tried
and failed), intend to engage the LHWs in case finding activities, and in monitoring
treatment. Further case finding strategies include intensified hospital: DOTS linkages,
contact-tracing of both the under 5s and, innovatively, those over the age of 5 years,
partnerships with community based organisations to find and support cases, and improved
advocacy and communications to stimulate public and health worker awareness of the
importance of TB.

2. The proportion of private general practitioners engaged in TB control will be increased in

almost all provinces from around 5% to around 20%, primarily through ensuring increased
awareness of the mandatory notification legislation and involvement of field staff who will
coordinate with GPs through a call centre system, which will facilitate firstly, registration of
the practitioner, then the diagnosis of presumptive cases, and the registration of a
confirmed, or clinically diagnosed, case.

3. To address the 24% of people who first attend the informal sector for treatment, this plan
includes a significant increase in the involvement of the informal providers (hakim,
pharmacists, homeopathic clinics and others). These providers will be trained to recognise
and refer presumptive cases, and linked with diagnostic facilities through informal networks
that will be strengthened.

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4. This plan aims to significantly increase the sensitivity of the diagnostic algorithm through far
greater use of MTB-RIF testing for the diagnosis of TB (not just for diagnosing DR-TB), while
ensuring that costs remain manageable through expanded use of chest X-ray as a screening
tool. The plan thus envisages supply of 102 additional X-ray machines over the four-year
period, with 1.6 million chest x-rays, and 2 million Xpert tests performed annually.

5. Most provinces and regions include a systematic approach to sputum transport from BHUs
to diagnostic facility, and from diagnostic facilities to GeneXpert sites, through outsourcing
to professional courier companies or suitable local solutions Regular timetables will be
established and patient visits timed to ensure that their specimens can be transported for
diagnosis with the minimum of delay.

6. This plan envisages federal level support for the establishment of a Central TB Programme to
act as a national level central unit, providing organisational and management support and
strategic and technical policy guidance to the provinces and regions on the introduction of
new techniques and technology. It will also strengthen the monitoring and evaluation of TB
control activities throughout the country, training of trainers of appropriate numbers of
medical, nursing and paramedical staff, establishing research priorities and a low-cost
mechanism for funding essential operational research, and to coordinate foreign and
domestic investment in TB control. The plan includes continued support to the National TB
Reference Laboratory at federal level to enhance its current role providing routine and
advanced mycobacteriology services , capacity development, quality assurance, surveillance
of drug resistance, research, and technical assistance for scaling up quality assured TB
laboratory services.

7. Monitoring and evaluation will be further enhanced primarily through accurate estimates of
the national burden of TB and its trend since the last survey in 2011, through a national
prevalence survey, powered to provide a significant result for each of the four provinces.
Further expansion of DHIS2 will facilitate gradual roll-out of case-based, web-based
electronic recording and reporting to the whole country over the four-year period.

8. This plan aims to secure and sustain political commitment, through continuous advocacy
directed at high level policy makers in Pakistan. It aims to increase national ownership and
oversight, increase the financing for TB especially via sustainable domestic resources, and
facilitate a supportive legal and regulatory environment. Pakistan will also adopt a multi-
sectoral approach with an accountability framework.

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 1. Introduction
1.1 What this NSP is
This National Strategic Plan (NSP) for 2020-2023 is the document that lays out the full expression of
Pakistan’s needs in controlling tuberculosis (TB), and describes the plan to meet those needs
between 2020 and 2023. The NSP will guide the interventions that Pakistan will undertake to
address its epidemic of TB. It takes into account the context of the national health system - both
private and public sectors – and government health policies and strategies. It is backed by an up-to-
date understanding of the epidemiology of TB in Pakistan, and the recommendations of the Joint
Pakistan Review Mission (JPRM) conducted in February 2019.

Crucially for Pakistan, this NSP, in line with the 18th Amendment of the Constitution, is built up from
the provincial strategic planning process of the provinces, territories and regions. The authors have
followed the clear instructions from Dr Rana Muhammad Safdar, National Coordinator, Central
Management Unit (CMU), and the Global Fund, that the national plan should be “built from the
bottom up” and fully reflect each province’s, territory’s and region’s aspirations and intentions.
Moreover, each province, territory and region has its own strategic plan to guide local actions, and
local investments.

This document forms the Core and the Monitoring and Evaluation components of the National Plan,
and describes the global, regional, national and provincial contexts for TB care, prevention and
treatment in Pakistan. It lays out the national vision, mission and goal as well as the objectives and
interventions to achieve that goal. It includes an assessment of all the main technical areas of TB
control in the country, which contribute to an overall gap analysis. The Budget Plan brings together
the costs for the Plan and will be summarised at the end of this document. The details of the budget
plan will be found in a separate excel file. The technical assistance and operational plans follow the
budget plan.

This NSP, and its provincial, regional and territorial counterparts, is therefore designed to guide the
actions not only of the Ministry of National Health Services, Regulations and Coordination
(MONHSRC), but also all decision-makers and implementers within the government at national,
provincial and regional levels, and in the non-governmental sector, both national and international,
whose work touches on TB control in the country. It should be the main guide for funding agencies
considering investment for TB control in Pakistan during this period.

1.2 Results of the Pakistan Joint TB Program Review Mission (JPRM) 2019
Objectives
The JPRM’s mission in February 2019, was to measure progress in the implementation of the TB
National Strategic Plan 2017-2020 and assess Pakistan's readiness to meet the commitments of the
United Nations General Assembly Political Declaration on TB. The mission sought to determine if
Pakistan’s TB Programme was supported by a broader health and development agenda including the
Sustainable Development Goals, and Universal Health Coverage. The JPRM reviewed programme
sustainability factors with a particular emphasis on domestic and international financing. It assessed
the progress in establishing a multi sectoral approach for ending the TB epidemic and in reaching the
End TB Strategy targets, with a focus on finding the missing cases of TB, and the prevention,
identification, care and treatment of drug resistant tuberculosis.

5
Findings
The burden of TB in Pakistan was still very high: in 2017, it was estimated that over half a million
people developed tuberculosis and well over 50,000 died from it. The gains that had been made to
keep TB “under control” were threatened by an increasing burden of drug resistant TB. In 2017, it
was estimated that Pakistan had more than 27,000 people with this form of TB.
The JPRM observed that the enormity of the TB health crisis in Pakistan was not familiar to sufficient
decision-makers at national or provincial level. On the contrary, several people thought TB had been
“eradicated” in Pakistan. Very limited effort had been made to establish and nurture the multi-
sectoral approach to TB care and prevention. No Multi–Sectoral Accountability Framework had
been set up.
Even though Pakistan had increased its effort to identify and place on treatment people who
develop TB, it was estimated that up to 200,000 people with TB and 25,000 people with drug
resistant TB were missed every year, either because they were not diagnosed at all, or, if diagnosed
(and perhaps treated), were not reported to the public system.
While significant progress had been made to find cases of TB, including expansion of TB diagnostic
services and engagement of private health care providers - and a significant increase in TB
case notification of about 22% had been observed between 2013 and 2017 - the number of persons
not reached with high quality TB services, including appropriate support, remained high.
Opportunities had been missed to engage the wide network of Primary Health Care services in the
public sector.
Similarly, the engagement of the very wide network of private health care service providers, who
provide about 85% of initial care to persons when they fall ill in Pakistan, had a coverage of a meagre
5% or less.
The TB response was financially very constrained. The TB National Strategic Plan, 2017-2020 was
budgeted at US$ 520 million. Of this only US$ 179 million (35%) had been made available, leaving a
gap of 65%. Additionally, of the available funding, US$ 144 million (80%), was from the Global Fund.
The over-dependence on external financing suggested a lack of ownership of the TB health crisis in
Pakistan. Thus, the TB situation in Pakistan qualified as a “continuing health emergency”, requiring
emergency-type actions to be addressed.
Recommendations
The JPRM recommended that Pakistan needed to secure and sustain political commitment in the
fight against TB as a demonstration of national ownership of the TB crisis. To this end, the JPRM
strongly advised the Prime Minister at the national level, and the Chief Ministers at the provincial
levels, to declare a Pakistan END TB Initiative, on or before World TB Day, 24th March 20191, and to
establish National / Provincial Steering Committees chaired and under the oversight of the Prime
Minister and Chief Ministers.
While recognising Pakistan’s constraints, the JPRM recommended a significant increase to the
Government’s contribution to anti-TB efforts, as well as contributions from the private sector and
development partners.
The JPRM also advised Pakistan to take immediate action to adopt a multi-sectoral approach - with
an accountability framework - under the oversight of the Prime Minister and the Chief Ministers -
with active involvement of all concerned ministries, local governments, private sector stakeholders,

1
WTBD 2019 was commemorated on April 3, 2019 in the Pakistani Presidency where the President of Pakistan
announced a TB Free initiative. However, this work has not moved forward owing to the expiry of the
contracts of the designated staff.

6
civil society organizations, affected communities, non – governmental organizations, academia and
others to track and reach the End TB and Sustainable Development Goals targets.
The JPRM crucially recommended expansion of quality TB service provision, both public and private,
to all levels of the health care system up to the community level. Given that the private health care
sector dominates the provision of health services in Pakistan, increasing the engagement of private
healthcare providers for TB was of paramount importance. National and Provincial TB Programmes
were advised to methodically expand TB service provision throughout all levels of the Primary Health
Care system. The JPRM thought that more cases of TB could be found if communities were more
engaged in TB responses, including integrating TB in the work of Lady Health Workers, and
addressing TB among key populations including PLHIV, prisoners and migrant/mobile populations.

Additionally, the JPRM criticised the targeting of Xpert testing. Although mostly employed to test
smear positive patients for rifampicin resistant (RR) TB, the numbers of RR-TB cases detected had
not risen much in previous years – from 3,243 in 2014 to 3,824 in 2018. Furthermore, the
proportion of drug sensitive cases that was clinically diagnosed had increased, rather than
decreased, which suggested that Xpert machines were being insufficiently used to detect TB among
the presumptive cases - thus limiting the impact on transmission, a key goal in TB prevention.
Comprehensively decentralized services were recommended to prevent, detect (as early possible),
and treat and care for both drug sensitive and drug resistant TB.

1.3 The NSP 2017-2020

1.3.1 Vision, goal, target and objectives
The 2017-2020 TB-NSP was ambitious, with a vision of a Pakistan without TB, and the goal of
effectively ending the TB epidemic by 2035 (Figure 1). The main target of the NSP was to reduce the
incidence of TB by 20%, by 2020, compared to 2015. However, this target was not measurable and
could be argued was over-ambitious. Nevertheless, the NSP was used as the basis for the funding
request to the Global Fund.

Figure 1. The vision, goal and target of the NSP 2017-2020.

The first four objectives (Table 1) mostly addressed the conventional TB control strategies first
formulated under the WHO’s DOTS strategy, and then re-worked as Pillar 1 of the End-TB strategy

7
(integrated patient centred TB care and prevention) endorsed by the World Health Assembly in
20142. The NSP added “Innovative care” to this pillar. The four objectives aimed to increase case
notifications and treatment success of both drug sensitive and drug-resistant TB. The interventions
or “programmatic components” to deliver these objectives list the main activities to be implemented
and the target groups. The “innovative” element refers to the target groups of the elderly, tobacco
users and diabetics. Objectives 5 and 6 aim to improve the support for TB in the policy environment,
and the only mention of public/private collaboration is here. Objective 7 is to establish research
collaboration to optimise “implementation and impact”.

Table 1. The objectives and programmatic components of the Pakistan NSP for TB, 2017-2020

1.3.2 Strategic directions

The NSP 2017-2020 describes strategic interventions or directions which flesh out the programmatic
components. These are listed in the plan by WHO’s three Pillars of the End TB Strategy.

Pillar 1. Innovative care; integrated patient centred care and prevention: search, treat and cure.
 Ensure early identification of presumptive TB cases (private, public).
 Provide universal access to quality TB diagnosis (including drug-resistant (DR) TB).
 Build capacity to HCW on existing screening methods for LTBI.
 Ensure early initiation of treatment to all patients diagnosed with TB.
 Improve TB treatment adherence.
 Prevent TB in key affected persons such as prisoners, miners, HCWs, children, injecting drug
users, and PLHIV.
 Implement behavioural support interventions developed through TB and tobacco trials in
routine settings.

2
WHO. The End TB Strategy. End TB Brochure, 2016, WHO, Geneva.
http://www.who.int/tb/End_TB_brochure.pdf?ua=1 Accessed 12 November, 2019.

8
Activities are listed in the plan, but in some areas, eg “Diagnosis”, p 101, they confuse descriptions of
what was happening at the time, with future plans. In “Contact management and case
identification”, p 102, the activities are generic, not clearly linked with each other, and non-specific.
Two diagnostic algorithms are shown, an “interim” and a “preferred” version, but there is no
discussion of which to use, or when, or rationale for so doing. In some areas, eg “Management of
DR-TB” the activities are significantly clearer, and connected up. However, even here, there are
important gaps, for example, the drugs to be used for preventive therapy of contacts of MDR-TB
cases are not mentioned. The activities for “TB in the elderly”, “TB in diabetics”, “TB and tobacco
smoking” are sketchy: those for TB/HIV sketchy and repetitive (p 108-9), although largely following
the WHO guidance on collaborative TB/HIV activities.

Pillar 2. Bold policies and supportive systems: Engage, support and care
 Secure high level political commitment and mobilise domestic resources towards ending TB.
 Link TB patients and households with social support schemes to reduce catastrophic out-of-
pocket expenditure to the patients.
 Increase number of private health care providers engaged with NTP and enhance scope of
services provided in line with ISTC standards of quality of care.
 Target behaviour change to generate demand for health services and empower communities
to play a role in accountability of health care provision.
 Prevent the loss of TB cases in the cascade of care within health system by HDL (treatment
supporters and linkage to care between primary and tertiary level).
 Legislate and implement regulatory mechanisms for mandatory TB disease notification and
rational use of ATT.
 Minimise the risk of disease transmission within populations through effective TB infection
control.
 Advocate for establishing a vital registration system in Pakistan.
 Strengthen partnerships within the health sector to enhance case detection and address
comorbidities.
 Capitalise on inter-sectoral partners’ strengths for TB care and support.

As in Pillar 1, the description of activities is mixed in terms of clarity, comprehensiveness, and

appropriateness, but those that are proposed for public-private mix (PPM) are mostly well-
structured, appropriate and clear (pp 116-7). Multi-sectoral collaborations are proposed and a few
benefits to TB control are mentioned (p 114 ), but no reasons are given for why the other sectors
should become engaged, or how they might be convinced to do so. The same criticism applies in the
“Community Engagement” section in discussion of engagement with other elements of the health
sector, eg Lady Health Workers (LHWs), and the Maternal, Neonatal and Child Health Programme
(MNCH).

Pillar 3. Intensified research and innovation: Seek, know, and apply

 Build supportive structures for surveillance, research and innovations at national and
provincial level
 Identify and prioritise research gaps
 Strengthen research capacity at local level
 Share research evidence and emerging best practice to strengthen policy and practice
 Strengthen the stewardship role of governments at all levels for research and knowledge
management systems
 Build institutional capacities to promote, undertake and utilise research for evidence based
policy-making in health at all levels

9
Many of the activities are clear, specific and appropriate.

1.3.3 What was achieved (and not achieved)

The main NSP 2017-2020 targets are not on course to be achieved (Table 2). Tuberculosis treatment
coverage (TC) for DS-TB and DR - TB should, by the end of 2019 be at 88% and 50% respectively but,
while there has been a tiny improvement from 63% in TC for DS-TB in 2015, the baseline year, to
64% in 2018, TC for DRTB is unchanged since 2016. Only 25% of notified cases of TB were tested
with a World Health Organization Recommended Rapid Test (WRD) in 2018 and almost all of these
were tested to detect rifampicin resistance, rather than to look for TB. There are no data on
coverage of treatment for latent TB infection (LTBI), and a patient cost survey has not yet been
conducted, so Pakistan may not be able to report to WHO on the proportion of TB patients who
experience catastrophic costs as a result of TB by 2020.

Table 2. Annual targets for the TB-NSP 2017-2020 and achievements by 2018 (all in percentages).
TC = treatment coverage, TS = treatment success rate, DS = drug sensitive, DR = drug resistant.

Indicator 2015 Target by year Achieved

baseline 2016 2017 2018 2019 2020 by 2018
TC:DS-TB 63 72 80 85 88 90 64
TC:DR-TB 20 21 30 40 50 60 21
TS:DS-TB 93 93 93 93 93 93 93
TS:DR-TB 69 72 72 73 74 75 64
Households with Survey to be planned and implemented Survey
catastrophic NA not done
expenditure

Funding of the NSP

There was a very large funding gap for the TB-NSP 2017-2020. Of the costed budget of US$520
million, only US$179 million was available through the Government and the Global Fund combined
(US$ 34 million or 7% of the total request, and US$144 million or 28% of the total, respectively),
leaving a financing gap of US$341 million or 65%. At the federal level, there were plans to increase
funding for health from consistently less than 1% of government spending for over 20 years, to
about 3%, but there is no evidence of progress3. At the provincial level, funding for TB has been
small and often based on project-type funding through the Planning Commission mechanism, known
as a PC1. The PC1 approach is a project-based mechanism in which funds are approved in principle,
but released subject to availability, typically only partially, and after delays. Over the last three
years, of the allocated funds, only 48% in 2016, 43% in 2017, and 51% in 2018 were released.
Challenges in inception
There was considerable delay in identifying and selecting a team of consultants (one international
and two national consultants) to support the NTP for NSP development. There were consultative
meetings with provinces and regions but there was insufficient time invested to win the trust and
ownership of provinces. At province level the NSP was largely perceived, though incorrectly, as an
activity of the central level. There was a lot of pressure to finalize the document in time for the
Global Fund application window. These lessons have been learned for the NSP 2020-2023, and the

3
Chapter 11, 2018-2019 Health and Nutrition Economic Survey.

10
result is a more bottom up approach, with greater emphasis and more time given to Provinces for
the development of their provincial plans.

The plan itself may not have been as clear as it could have been, and the strategies proposed were
conventional, even conservative, but the activities were rational. Other countries have made much
greater strides in reducing their TB burden using similar strategies, eg Cambodia, Thailand, and
Myanmar. Had the strategies been fully implemented, it is likely that they would have made a much
bigger impact than they have so far.

The inevitable conclusion is that the main reason the NSP 2017-2020 has not achieved much
progress beyond the 2015 baseline is because it was never adequately funded. The supply of both
federal and provincial funds was meagre. Government commitment was absent, as noted by the
JPRM. Lack of domestic funding and political ownership were the main limiting factors. Weakening
of the central unit’s role as a national-provincial interface in the post devolution scenario resulted in
poor advocacy from the Federal level in support of domestic resource mobilization from the
provinces. There may also have been a lack of understanding that the NSP was a full expression of
demand (programmatic & financial) aimed at securing both domestic financing, as well as donor
funding.

In spite of over 25 years of global advocacy, including the Moscow Ministerial Conference on TB and
the UN High Level Meeting in 2018, the JPRM makes clear that provincial and federal decision-
makers have failed to recognise the health burden, and the tragic social consequences, due to TB.
They have therefore failed to release sufficient funds to make a difference to the TB epidemic in
Pakistan. (A more detailed exploration of health expenditures follows below in Section 2.2.5 and
2.3.3).

1.4 Process of development of this NSP

The goal of the development process was to have the NSP ready by mid-December 2019, in order to
formulate the funding request for the Global Fund in Quarter 1 of 2020, so that funds could be
certain to flow to the country by January 2021. Important preparatory milestones were achieved,
notably the epidemiological analysis, through the medium of a “patient-centred workshop” in
January 2019, and the Joint Review Mission in February, 2019.

Since the 18th Amendment, health is a provincial issue, and this NSP has therefore been constructed
from the four provincial strategic plans (PSP) and those from the regions and territories, with
guidance at each step provided by the international consultant, Paul Nunn.

An NTP national advisory team on the NSP was constituted with staff from the NTP and from the
WHO country office, Islamabad. Six national consultants were recruited, one for each province, one
for the regions and territories as a whole, and one to support the budget preparation. The national
NSP team organised the following steps:

1. A three day national consultation was held in September 2019 which decided on the
goal of the NSP and its associated targets, broken down for each province, region and
territory. The targets selected were adapted from the national End TB targets prepared
by the Stop TB Partnership, Geneva, from the global targets set by the UN High Level

11
 Meeting4, and were intended to be measurable, and in line with international guidance5.
The priority areas, the structure and alignment of the NSP and PSPs and the provincial
and federal consultation framework were also agreed upon. The participants included
people with TB, members of civil society and of the CCM, Stop TB Pakistan, MoNHSRC
staff and members of the Technical Working Group on TB, NTP, PTP and RTP staff, but
no staff from Ministries that might be thought to have an interest in TB work. The
private sector was represented by Indus Hospital Network, Mercy Corps, Greenstar
Social Marketing, and Aga Khan University. Day 3 of the meeting exclusively focused on
consultations with the Provinces of KP, and Balochistan, ICT, FATA , AJK and GB.
2. Two 2-day provincial consultations were held in each of the provinces of Punjab and
Sindh.
3. A similar round of meetings was then held in October, 2019 to present the early versions
of the plans and ensure alignment. These meetings were also used to encourage
participation of the private sector, which had been rather standing back from the
process, especially in Punjab and Sindh. The type and quality of interventions was
discussed further in attempts to make the plans achievable and focused and to increase
the probability of achieving the targets. The set of indicators was drafted, based on the
End TB targets, and including the top 10 targets of the WHO End TB Strategy6.
4. The PSPs and RSPs were submitted during November 2019 to the international
consultant for comment and for incorporation into the NSP. Budgets were prepared at
the same time and synthesized for the national budget.
5. The regional and territorial budgets took longer than anticipated to assemble, but were
all ready by early January. The NSP Core, Monitoring and Evaluation (M&E), and
Technical Assistance (TA) Plans were finalised and submitted for approval at the
Endorsement Meeting, January 20-21, 2020.

2. Background
2.1 Global TB context
2.1.1 Global epidemiology of TB
Globally, an estimated 10.0 million (95% uncertainty interval, 9.0–11.1 million) people fell ill with TB
in 2018, a number that has been relatively stable in recent years7. The slow decline in incidence of
about 1.6% per year between 2000 and 2018 is offset by the rise in population. Men account for
57% of the cases, women for 32%, and children, 11%. Two-thirds of the cases occurred in Africa and
East Asia, while 8% occurred in the Eastern Mediterranean Region, in which Pakistan is the largest
country. Pakistan alone accounted for 6% of the global incidence, and is ranked 5th in the world for
TB incidence.
TB is a fatal disease if left untreated, and it is the top infectious killer worldwide, causing more
deaths than HIV/AIDS. About 1.45 million people are estimated to have died with TB in 2018, of
whom a quarter of a million were infected with HIV. Drug resistance is perceived as a major threat,

4
UNHLM, 2018.
http://stoptb.org/assets/documents/global/advocacy/unhlm/UNHLM_Targets&Commitments.pdf Accessed
November 13, 2019.
5
Harries AD, Lin Y, Kumar AMV et al. What can National TB Control Programmes in low- and middle-income
countries do to end tuberculosis by 2030? F1000Res. 2018; 7: F1000 Faculty Rev-1011.
Published online 2018 Jul 5. doi: 10.12688/f1000research.14821.1
6
WHO, 2015. Implementing the End TB Strategy: the essentials. WHO, Geneva.
7
WHO, 2019. Global Tuberculosis Report. WHO, Geneva.

12
with about half a million cases of rifampicin resistance in 2018, of whom 78% would have had multi-
drug resistant TB.

2.1.2 Global political response

At the 2014 World Health Assembly in Geneva, Pakistan committed to the End TB Strategy, which
aims to end the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases
by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic
expenses due to TB. It sets interim milestones for 2020, 2025, and 2030 (Table 3).

Similarly, Pakistan is signed up to the United Nations’ (UN) Sustainable Development Goals whose
Goal 3 addresses health, and aims by 2030, to end the epidemics of AIDS, tuberculosis, malaria and
neglected tropical diseases8. In November, 2017, Pakistan attended the Moscow Ministerial
Conference organised by WHO to increase commitment globally to reduce the burden of TB. The
comment of the WHO’s Director-General was especially apt for Pakistan: "One of the main problems
has been a lack of political will and inadequate investment in fighting TB," added Dr Tedros. "Today’s
declaration must go hand-in-hand with increased investment."9

Table 3. The WHO End TB Strategy main indicators, milestones and targets

MILESTONES TARGETS
INDICATORS 2020 2025 2030 2035

1. Reduction in TB incidence rate compared

20% 50% 80% 90%
with 2015 (%)
2. Reduction in number of TB deaths
35% 75% 90% 95%
compared with 2015 (%)
3. Percentage of TB patients and their
households facing catastrophic costs due to Zero Zero Zero Zero
TB

The Ministerial Conference was followed in September, 2018 by the unprecedented UN High Level
Meeting on TB (UNHLM), during the General Assembly in New York. Heads of States and
Governments committed to several actions through endorsement of a political declaration which is
expected to lead to ending the public health menace of TB - if fully implemented. Governments
committed to increase financing for TB, establish robust multi-sectoral responses to the fight against
TB, increase identification and treatment of TB to narrow and then eliminate TB case finding gaps,
and to increase funding for research into discovery of new tools (diagnostics, medicines and
vaccines) and new delivery systems through operational research. Pakistan was a signatory to the
declarations that were made at both the Ministerial Conference and the UNHLM.

2.1.3 Global achievements against the targets

Seven million cases of TB were notified and started on treatment in 2018, which hit the target for
case finding that year, and was up from 6.4 million in 2017. The bulk of this increase was almost

8
United Nations Sustainable Development Goals. http://www.un.org/sustainabledevelopment/health/
Accessed November 13, 2019.
9
WHO. News Release, 17 November, 2017. https://www.who.int/en/news-room/detail/17-11-2017-new-
global-commitment-to-end-tuberculosis Accessed November 13, 2019.

13
entirely due to the increases in notification in India and Indonesia, the two highest burden countries.
Notwithstanding this performance, 3.0 million cases around the world were not notified.
Furthermore only one third of the half million rifampicin resistant cases were started on treatment.

Case finding may be on track, but the reduction in estimated incidence between 2015 and 2018 is
only one third of the target for that period. The treatment success rate target is 90%, but was only
85% in the cohort treated in 2017, although this is an increase on the 81% in 2016.

The preventive treatment target is 30 million for the 5 years between 2018 and 2022, 6 million
people living with HIV (PLHIV) and 22 million household contacts. While 1.8 million PLHIV took
preventive treatment in 2018, suggesting the 5 year target is achievable for this sub-group, only
350,000 contacts of 5 years or below, were treated, and 80,000 above the age of 5 years. There is a
long way to go before the targets for preventive treatment are reached.

As for funding, only US$ 6.8 billion is budgeted for 2019, which is US$ 3.3 billion less than the target
required by the Stop TB Global Plan to End TB, 2018-2022, but about 50% of the target set by the
UNHLM.

2.2 National context

2.2.1 Geography
The Islamic Republic of Pakistan is in South Asia and borders India to the East, Afghanistan to the
West, Iran to the South West and China to the far North West. The 2,430 km long border with
Afghanistan is particularly important for TB care and prevention in Pakistan because of the
movement of Afghans into Pakistan to seek medical care, particularly in facilities offering specialized
services. The country is administratively divided into the Islamabad Capital Territory (ICT); 4
provinces: Balochistan , Khyber–Pakhtunkhwa (KP), Punjab and Sindh; and two regions (Gilgit-
Baltistan (GB) and Azad Jammu and Kashmir (AJK)) and the Federally Administered Tribal Areas
(FATA), which are officially to be merged with KP: the 25th Amendment of the Constitution on 31
May 2018 signified that FATA was officially merged with Khyber Pakhtunkhwa. However, de facto,
the merger will take many years to complete. Since no concrete steps have yet been taken to merge
heath service delivery, for the purposes of this NSP, they will be regarded as separate.

2.2.2 Population
The population of Pakistan has been steadily increasing in recent times (Figure 2) and was officially
estimated in 2018 at 212 million, based on the 2017 census, with a 2% estimated annual increase10.
This would make the 2019 mid-year population 216 million and Pakistan the sixth largest country by
population. The only recent total population figure available on the Pakistan Bureau of Statistics
website is 207 million in 201711. However, no further commentary or assumptions are given,
although the census data by block are available. Many informants in Pakistan asserted that
undercounting was known to have occurred in some blocks in the census, especially in the regions
and tribal areas.

The provinces, territories and regions base their population figures on the 2017 estimates, with
province, territory and region-specific annual growth rates which vary from 0.6% in Balochistan to
2.9% in KP.

10
Wikipedia. https://en.wikipedia.org/wiki/Demographics_of_Pakistan Accessed 13 November 2019.
11
Pakistan Bureau of Statistics. http://www.pbs.gov.pk/content/population-census Accessed 13 November
2019.

14
There have been drastic social changes in Pakistan which have ushered in a new era of urbanization
and the creation of a couple of megacities within the country – Karachi and Lahore. The country is
now one of the most urbanized cities in all of South Asia - city dwellers make up about 36% of the
entire population. About 50% of Pakistani citizens live in a place where at least 5,000 other citizens
reside as well12.

The population growth rate in Pakistan is expected to halve to less than 1% by the year 2050. The
population is predicted to near 210 million by 2020 and 245 million by 2030, but is not expected to
stabilise until the end of this century, when it is predicted it will have reached 364 million.

Figure 2. Population of Pakistan from 1900 to 2018 (millions). Source: The World Bank13

Pakistan is a youthful country, with over 53% of the population below the age of 24 years, while only
10% of the population is 55 years or older (Figure 3). However, the population is ageing, and the
proportion of older people is expected to double by 2050. This ageing is already putting a strain on
the provision of health services14, and over time, will put further upwards pressure on the incidence
of TB. There are slightly more males than females in the country. Life expectancy at birth in 2019
is 67 years, up from less than 40 in 195015. This compares with 69 for India, and nearly 77 years in
Sri Lanka.
Approximately 8.8 million Pakistanis live abroad, with the vast majority, over 4.7 million, residing in
the Middle East. The second largest community, at around 1.2 million, live in the United Kingdom16.
According to the UN Department of Economic and Social Affairs, Pakistan has the 6th largest
diaspora in the world. As far as we can find, no sex differences are reported among out-migrants,
but the majority are assumed to be male. In 2017, overseas Pakistanis sent remittances amounting
to US$15 billion.

Figure 3. The Pakistan population pyramid, 2018.

12
World Population Review. http://worldpopulationreview.com/countries/pakistan-population/ Accessed 26
November, 2019.
13
The World Bank. https://data.worldbank.org/country/pakistan Accessed 24 October 2019.
14
Ashiq U, Asad AZ. 2017. The rising old-age problem in Pakistan. Journal of the Research Society of Pakistan
Volume No. 54; 2: 325-333
15
https://www.macrotrends.net/countries/PAK/pakistan/life-expectancy Accessed 26 November, 2019.
16
Wikipedia. https://en.wikipedia.org/wiki/Overseas_Pakistani#1971_to_present Accessed 26 November,
2019.

15
 Source : https://www.populationpyramid.net/pakistan/2018/

2.2.3 Politics
Pakistan is currently a multi-party democracy, but has passed through several phases of military
government since independence from Britain in 1947. The country is a federal parliamentary
republic in which, since the 18th Amendment, passed in 2010, provincial governments enjoy a high
degree of autonomy. Executive power is vested with the national cabinet which is headed by the
prime minister. The nominal head of state is the President who is elected by an electoral college for
a five-year term, but whose major powers were stripped away by the 18th amendment. Since then,
Pakistan has had a purely parliamentary government.

The current Prime Minister is Imran Khan, well-known to cricket fans, who is the head of the
Pakistan Tehreek-e-Insaf (PTI) party. Following the 2018 election campaign, the PTI party won 116
of the 272 seats available, and has joined with several smaller parties to form a majority in
parliament, which looks stable.

2.2.4 Socio-economic development

The economy of Pakistan, as judged by measures of gross domestic production (GDP) has been
increasing in size since 1990, with several plateaus relating to political events (Figure 4). A
nominal GDP per capita of US$1,357 in 2019, ranks it 154th in the world and giving it a purchasing
power parity (PPP) GDP per capita of US$ 5,839 in 201917. However, Pakistan's undocumented
economy is estimated to be 36% of its overall economy, which is not taken into consideration when
calculating per capita income. Pakistan is a developing country, but is thought by some economists
to have a high potential of becoming, along with the BRICS countries, one of the world's largest

17
Wikipedia. https://en.wikipedia.org/wiki/Economy_of_Pakistan Accessed 26 November, 2019.

16
economies in the 21st century. In 2019, however, the economy was semi-industrialized, with
centres of growth along the Indus River. Primary export commodities include textiles, leather goods,
sports goods, chemicals, carpets/rugs and medical instruments.
The diversified economies of Karachi and major urban centres in the Punjab coexist with less
developed areas in other parts of the country. The economy has suffered in the past from internal
political disputes, a fast-growing population, and mixed levels of foreign investment. Foreign
exchange reserves are bolstered by steady worker remittances, but a growing current account
deficit – driven by a widening trade gap as import growth outstrips export expansion – could draw
down reserves and dampen GDP growth in the medium term. Pakistan is currently undergoing a
process of economic liberalization, including privatization of all government corporations, aimed at
attracting foreign investment and cutting the budget deficit.
In October 2016, the IMF chief Christine Lagarde confirmed her economic assessment that Pakistan's
economy was 'out of crisis', in large part because it was benefitting from Chinese investment. In May
2019, though, the IMF predicted that future growth rates would be 2.9%, the lowest in South Asia.
Nevertheless, poverty in Pakistan fell from 64.3% in 2002 to 29.5% in 2014.
Figure 4. GDP per capita by purchasing power parity (PPP) in 2011 (constant US $ in thousands).
Source: The World Bank18

2.2.5 Health expenditure

Total health expenditure was 3.1% of GDP as of 2016, down from a peak of 3.4% in 2006 (Table 4).
Of total health expenditure in Pakistan, 34% is funded by the public sector19. The government’s
contribution to total health expenditure in terms of GDP is about 1%. At US$ 11, the per capita
annual government expenditure on health is one of the lowest in the world20.

18
The World Bank. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.CD?locations=PK Accessed 24
October 2019.
19
Pakistan Bureau of Statistics. The National Health Accounts, 2015-2016.
20
IHME. http://www.healthdata.org/pakistan Accessed 10th December 2019.

17
Out of total public sector health expenditures, 21.8% are funded by the federal government - 58%
from its civilian part and 42% from its military component. Around 64.4% of total health
expenditures are funded through the private sector out of which 89% is out of pocket (OOP) health
expenditures by private households. OOP health expenditure in Pakistan was therefore about 57%
in 2016, as a percentage of total expenditure on health, which amounts to over Rs 1,000 per
household per month. The ratio of general government health expenditures to total general
government final consumption expenditure was nearly 10% (9.7%) in 2016, but this denominator
probably excludes military spending.

The government’s federal budget of 2017-2018 (1 July to 30 June) was Rs 4.75 billion, which
increased with Prime Minister Imran Khan’s first budget to Rs 5.9 billion for 2018-2019. It was
difficult to tease out the total government health budget from the reports available. Some health
projects and programmes saw an increase in budget, eg Health Affairs and Services, which includes
hospitals, but others did not, eg the Public Sector Development Programme. There was no specific
mention of TB, or even infectious diseases, or public health programmes, in the budget reports21.
The budget was clearly an attempt to stimulate the economy.

Table 4. Main health economic indicators from the National Health Accounts

Pakistan is spending the lowest on health in the Eastern Mediterranean Region22. At the same time,
however, health departments are not able to spend the disbursements completely. A significant
amount of budget stays unspent at the end of the fiscal year. “Proper financial management is a big
issue”, according to the inter-ministerial council. One Provincial Minister reported that budgets are
not evidence based and there are a lot of procedural delays due to unnecessarily lengthy bureaucratic
and legal processes.

2.2.4 National health structure

Pakistan has a mixed health system, which includes government (public) infrastructure, para-statal
health institutions, the private sector, civil society and philanthropic contributors. A major strength
of the public health care system in Pakistan is considered to be its outreach primary health care,
delivered at the community level by 100,000 Lady Health Workers (LHWs), and an increasing number
of community midwives (CMWs), and other community based workers. Complementary, alternative
and traditional systems of healing are also popular in Pakistan. Not all practitioners in these areas
are qualified.

Public health care is delivered in the provinces mainly through a chain of primary, secondary and
tertiary level health facilities. The primary health care facilities include civil dispensaries, basic health
units (BHU), rural health centres (RHC), MCH Centres, urban health units and urban health centres

21
The News, Pakistan. https://www.thenews.com.pk/latest/310231-here-is-all-you-want-to-know-about-
budget-2018-19 Accessed 3 December 2019.
22
Inter-ministerial health and population council meeting, June 2019.

18
(Table 5). The secondary level health care facilities comprise taluka (tehsil) hospitals and district
hospitals. Tertiary level health care is provided through teaching and specialized hospitals.

However, multiple public sector agencies also have large hospitals – the para-statal health
institutions - such as the military hospitals, which also provide services to the dependents of service
personnel, and the Pakistan Railways. Employee social security systems, such as the Sindh
Employees Social Services Institution (SESSI), also provide services to labourers working in factories
and their families through networks of health facilities, including hospitals, in many major cities.
Furthermore, health services are also provided by various other agencies to their own employees
like Pakistan International Airlines (PIA), the Water and Power Development Authority (WAPDA),
utilities such as K-Electric, based in Karachi, the Pakistan Steel Mills, Karachi Port Trust, Sui Southern
Gas Company, Pakistan Petroleum Limited, Oil and Gas Development Corporation etc.. Only a
minority of these public and private facilities has a TB Basic Management Unit, or is engaged in
anyway with public sector TB control activities.

A series of programmes and projects are on track in Pakistan to improve the health status of the
people and to reduce the burden of communicable and non-communicable diseases while vertical
programs have been devolved to the provinces. There have been significant increases in the number
of facilities within the public health service, and the official numbers for 2018 are in Table 5. These
facilities together with over 220,000 registered doctors, more than 22,000 registered dentists and
108,000 registered nurses bring the current ratio of one doctor to every 963 people. By the end of
2018 there was one hospital bed for every 1,608 people.

Table 5. Estimated Number and type of the major public health facilities in Pakistan, 2018. Source:
NTP.

Facility Type Catchment population Number

Dispensaries 25,000-50,000 5,671

Basic Health Units 25,000- 50,000 5,202

Rural Health Centres 100,000- 250,000 686

Tehsil headquarters 0.5-1.0 million

hospitals (THQ)
450
District headquarters
1-3 million
hospitals

Public tertiary and

specialised hospitals National access

In Pakistan, the private health sector is a hugely significant component of the health sector: an
estimated 84% of initial healthcare seeking takes place in the private sector, 24% with informal
providers and 61% with formal providers, especially GPs23. Private healthcare providers include at
least 100,000 GPs, over 67,000 pharmacies, thousands of laboratories, and around 5,000 hospitals.

Patient Pathway Analysis; Report of National Workshop on Data and Evidence for Policy Actions Towards
23

Ending TB in Pakistan; Jan 2019

19
While they are concentrated in urban areas, GPs and informal providers also serve small towns in rural
areas.

Public-private mix approaches for TB have been explored in recent years and will be addressed below
(Section 2.4.4).

2.2.5 Health performance

Pakistan is facing a double burden of disease (BoD) and the burden is higher in the poor.
Communicable diseases, maternal health issues and under-nutrition dominate and constitute about
half of the burden of disease, with non-communicable diseases the remainder. With Afghanistan and
Nigeria, Pakistan is one of only three remaining countries where polio is still endemic. Population
growth is recognised as a challenge, and access to contraception is failing to meet women’s needs.

Non-communicable diseases (NCDs) along with injuries and mental health, now constitute over half
of the burden of disease, causing disabilities and premature deaths among the economically
productive adult age groups, as well as among the retired. The government recognises that the
common underlying factors for NCDs, which include lifestyle, nutrition and smoking have not been
addressed adequately. Injuries account for more than 11% of the total disease burden, and are
likely to rise. With respect to risk factors for TB, Pakistan is ranked 7th highest in the world for
diabetes prevalence, and smoking levels are high - 38% among men and 7% among women.

The Government of Pakistan (GoP) recognises that vertical service delivery structures and low
accountability for performance within the public sector reduce efficiency and quality of provision.
The public sector is inadequately staffed and job satisfaction and work environment need
improvement. Largely unregulated for quality and appropriateness of care and pricing, there is also
duplication of services by the private sector (see below). Unsurprisingly, the private sector
contributes least towards preventive and promotive health services. The health sector, overall, also
faces an imbalance in the number, skill mix and deployment of the health workforce, and
inadequate resource allocation across different levels of health care i.e. primary, secondary and
tertiary.

Overall health performance can be looked at in different ways, but health access and quality (HAQ) is
key. The HAQ indicator provides a summary measure of healthcare access and quality and is based
on an assessment of risk of mortality from causes that, in the presence of quality healthcare, should
not result in death. Pakistan’s HAQ indicator improved from 26.8 in 1990 to 37.6 in 201624 –Pakistan
ranks 154th in the world25 for its HAQ status – in exactly the same position as its ranking on GDP per
capita.

In some aspects, however, Pakistan ranks rather below its overall position, particularly in relation to
child health, especially immunisation rates and under 5 mortality (Table 6). Interestingly, it also
ranks 10th in the world for mobile phone subscriptions.

National indicators in Pakistan, however, conceal significant variation between provinces, and even
more between provinces and territories – Punjab and ICT generally having better health indices than
AJK, GB and FATA, with the other provinces in between.

24
IHME. http://www.healthdata.org/pakistan Accessed 14th December, 2019
25
GBD 2016 Healthcare Access and Quality Collaborators. Measuring performance on the Healthcare Access
and Quality Index for 195 countries and territories and selected subnational locations. Lancet, 2018: 391;
2236-71

20
Table 6. Recent general health indicators. Sources: see Table

Indicator Date Value International

Ranking
Maternal mortality rate 2017 140 (per 100,000 live 130th27
births)26
Under 5 mortality rate 2018 69.3 (per 1,000 live births) 169th28
Measles immunization 2018 76% 176th29
Neonatal tetanus cases 2015 667 -
HIV prevalence 2018 0.1% -
Fertility rate 2017 3.6 (births per woman) -
Mobile phone 2018 72.6% 10th30
subscriptions
2.2.6 Health priorities, policies, strategies and regulatory frameworks
National Health Vision
There is a national vision for health31, developed in 2016, which promises “universal access to
affordable quality essential health services, delivered through resilient and responsive health
system,… and to attain the Sustainable Development Goals”. It states that the national vision is
within the framework of post 18th Amendment Constitutional roles/responsibilities, but
government: province coordination mechanisms are not clearly laid out.

The vision aims to build convergence with important national programs and policy settings such as
the Pakistan Vision 2025, the Poverty Reduction Strategy, and pro-poor social protection initiatives.

While, “government is cognizant that adequate, responsive and efficient health financing is the
cornerstone of a country’s well-functioning health systems”, the vision’s promise that “Federal and
Provincial governments will increase allocation to health … to 3% of GDP” had not yet materialised
by 2018, thus placing in doubt that the vision can be financed.

The National Health Vision has five objectives, most of which focus on aspects of central
government: provincial coordination. Of note for TB control, is that the GoP “will be encouraging
and supporting the integration of vertical programmes at the provincial level for optimal and
efficient utilization of resources and better performance”. What this may mean in practice is not
spelt out. However, “governments will be enforcing the public health laws promulgated, related to
smoking, drug safety, … etc.”, although there is no reference to mandatory notification of infectious
diseases. Collaboration with the private sector is seen as essential: “Efforts would be geared toward
building synergies with the private sector in essential health services delivery (preventive and
curative)”.

26
https://knoema.com/atlas/Pakistan/Maternal-mortality-ratio Accessed 14th December, 2019
27
https://en.wikipedia.org/wiki/List_of_countries_by_maternal_mortality_ratio Accessed 14th December,
2019
28
https://www.indexmundi.com/facts/indicators/SH.DYN.MORT/rankings Accessed 14th December, 2019
29
https://www.indexmundi.com/facts/indicators/SH.IMM.MEAS/rankings Accessed 14th December, 2019
30
https://www.theglobaleconomy.com/rankings/Mobile_phone_subscribers/ Accessed 14th December, 2019
31
MoNHSRC. National Health Vision, 2016-2025.

21
Disease control
In November, 2019, Pakistan became the first country32 to adopt the 3rd edition of Disease Control
Priorities, DCP - 333, which is a global package of Essential Health Services brought together by more
than 500 scholars, policy makers and technical experts. It consists of a concrete set of priorities for
universal health coverage (UHC), “grounded in economic reality and intended to prove appropriate
to the health needs and constraints of low- and middle-income countries (LMICs), by (1) developing
a model benefits package referred to as essential UHC (EUHC); (2) identifying a subset of
interventions termed the highest-priority package (HPP); and (3) presenting a case all countries—
including low-income countries—could strive to fully implement the HPP interventions by the end of
the Sustainable Development Goals.” Pakistan is in the process of developing the Essential Universal
Health Coverage (EUHC) Package in line with the DCP3. This will reorganize the health services across
the country and will eventually be linked with health insurance.

Multi-sectoral involvement in health

The End TB Strategy is facing problems in country-level implementation of its second pillar34 – bold
policies and supportive systems - which promotes “strategic actions within and beyond the health
sector” to contribute to the implementation of policies that will address TB, as well as other benefits
and health advantages, eg Ministries of Food or Agriculture placing restrictions on sugar content of
fizzy drinks to limit the rise of diabetes, a major risk factor for TB.

In response, WHO’s Global TB Programme is pursuing multi-sectoral involvement in health35 through

its Multi-sectoral Accountability Framework (MSAF). The aims are to accelerate the multi-sectoral
response to the tuberculosis epidemic at global, regional and country levels, in recognition of the
fact that investments and actions were falling short of those needed to reach the targets and
milestones of the WHO End TB Strategy and the target of ending the epidemic by 2030 that is part of
the United Nations Sustainable Development Goals.

In Pakistan, the Inter-Ministerial Health & Population Council of Pakistan has met once on 20th June
2019, chaired by the Special Assistant to Prime Minister/ Minister of State, Dr. Zafar Mirza with the
Health and Population Ministers from the Provinces and Federal Areas. They addressed TB, noting
that a huge funding gap exists in the TB Programme. All provincial ministers were urged to enhance
domestic funding and address case detection and better management of drug resistant TB. It was
suggested that a National Awareness Campaign of 2-4 weeks may be launched engaging community
as well as health care providers.

This Inter-Ministerial Group, however, brings together the national Special Adviser/Minister and his
provincial/regional/territorial counterparts. That is, all the participants come from within the health
sector, and not from outside, thus limiting the group’s impact on multi-sectoral advances. In any
case, further work on the MSAF seems unlikely in the immediate future due to abolition of the
partnership development post in the NTP that was intended to address this issue.

32
https://en.dailypakistan.com.pk/25-Nov-2019/pakistan-becomes-first-in-world-to-adopt-disease-control-
priorities-3 Accessed 14th December
33
Disease Control Priorities. DCP3. http://dcp-3.org/ Accessed 14th December
34
Nunn PP. A review of national strategic plans for tuberculosis in the countries of the WHO South East Asia Region, as of
December 2017. Prepared for WHO, SEARO.
35
WHO, 2018. The multi-sectoral accountability framework: to accelerate progress to end TB by 2030. WHO,
Geneva.

22
 2.2.7 Social protection for health
The Sehat Sahulat Progrmme (SSP)
The MoNHSRC, in collaboration with provincial governments, has started a social protection
initiative for health care, the Sehat Sahulat Programme, previously known as the Prime Minister’s
National Health Programme. The objective is to lead a path towards Universal Health Coverage
(UHC) in Pakistan, with special focus towards those living below the poverty line in the country. The
program is being implemented in a phased manner.
By February 2019, this programme was covering 38 districts and had contracted 154 public and
private hospitals. When fully rolled out the SSP should cover over 50% of the Pakistani population.
For now, the program does not cover primary care. The identification of beneficiaries is based on
household poverty surveys where every household is scored between 0-100 with 0 being the
poorest and 100 the richest. A score of 16 is equivalent to a daily income of one US$. A new poverty
survey is currently ongoing.
Access to SSP benefits depends upon receiving an Insaf card, which can be obtained through sending
the citizen’s National Identity Card Number via SMS with to the SSP number, and if eligible, the card
is received from the district SSP distribution centre. Once admitted, the patient’s costs are charged
to the Sehat Insaf card, and the hospital is reimbursed.
In Phase I of the SSP each enrolled family is insured for up to Rs. 50,000 per year for secondary care
treatment and up to Rs. 250,000 per year for 7 priority care treatments – which do not include TB, as
TB treatment is already supplied free of charge. Patients who have consumed their limits will be
provided with additional limits by Pakistan Bait-ul-Mal.
In Phase II of the SSP, the benefit package of each enrolled family will be raised to Rs. 120,000 per
year for secondary, inpatient (indoor), care and treatment and up to Rs. 600,000 per year for
treatment related to 8 priority diseases or illnesses – still not including TB.
SSP is a cashless scheme in which no cash assistance or cash transfers will be provided to the
beneficiary except in-patient health care services and a traveling allowance of Rs. 350 per discharge,
for a total of 3 discharges per year, from residence to hospital and back. In Phase-II of SSP, this will
be increased to Rs. 1,000.

As of 9th February 2019, a total of 3,237,660 families had been enrolled in the SSP and more than
117,726 families have been treated for various illnesses from 157 empanelled hospitals across
Pakistan. There is also an option of inter district portability in the program which enables the
enrolled beneficiaries and families to access quality in-patient hospital services from any empanelled
hospital, both in the public and private sectors.
The SSP is being implemented through the State Life Insurance Corporation of Pakistan, hired
through an open and transparent bidding process. Services are delivered to the beneficiaries by
empanelling secondary and tertiary level health care facilities, both in the public and private sectors,
in all involved districts and metropolitan cities. The hospital empanelling is based on pre-established
criteria.

Bait-ul-Mal
Pakistan’s Bait-ul-Mal or (PBM) is a charity and social welfare organisation to help the poor and
needy in Pakistan. It is a semi-autonomous body set up through a 1992 Act of the Government of
Pakistan and provides financial help to “deserving poor people” earning less than Rs 10,000 per
month. Established in 1992 through an act of parliament and funded largely by the
Government, it has an annual budget of about of Rs 5-6 billion. It is present in every district in which
a team checks eligibility of would be beneficiaries using a standard check list. Beneficiaries receive
support that does not exceed Rs 600,000 per patient. Interestingly for TB, PBM also has residential

23
accommodation in shelter homes for the deserving homeless and abandoned elderly people, and
has set up free hospitals and rehabilitation centres for the poor to provide free medical treatment.
There are no current links between PBM and any of the provincial or regional TB services.
Benazir Income Support Program (BISP)
Initiated in 2008, the BISP is a cash transfer program that reaches about 5.2 million women across
Pakistan. Each woman receives about USD 40 every quarter. Through this program, nearly 60 million
people (the women and their families) are reached. The beneficiaries are identified through poverty
surveys as in the PBM program and the program has a dynamic registry. The Government of Pakistan
spends about USD1.2 billion on this program with 86% of the funding coming from domestic sources.
The other donors include World Bank/Asian Development Bank (ADB) and the United Kingdom’s
Department for International Development (DFID). A major focus of this program is addressing
malnutrition. The cash transfers are currently non-conditional but there are plans to explore
conditionalities through complementary opportunities which may include cash transfers for
educational programs in which the beneficiary is given an incentive to take her child to school.
Social protection for people or families with TB
Existing social protection mechanisms, the SSP and Biat-ul-Mal, do not specifically provide cover for
TB services. In any case, TB is mostly diagnosed and treated in the Out Patient Department (OPD),
while the Sehat Insaf card only covers indoor (inpatient) expenses. The Global Fund has been
providing significant financial support for patients (and families) with MDR-TB (Rs1000 for patients
and Rs600 for travel for the patient ,and Rs600 for a supporter, per month).

2.3 National tuberculosis situation

2.3.1 Organisation and management of TB services
Major implementing agencies – Federal level
The National TB Control Programme (NTP) was established in July 2000 for country wide
implementation of the DOTS strategy. The GoP had adopted the DOTS strategy in 1995, and in 2001
declared TB as a National Emergency - the “Islamabad Declaration”, giving the NTP the mandate to
design and regulate TB control activities in the country utilizing both domestic and donor resources.
The programme has been decentralized to provincial and district level and integrated with Primary
Health Care services. It is also moving towards integration in secondary and tertiary care services.
Since the 18th Constitutional Amendment in 2011, the provincial governments are mainly responsible
for dealing with health related matters in their jurisdiction, and their Provincial TB Control Programs
are now responsible for the organisation and management of provincial TB services.

The National TB Control Programme was reinforced through a GoP, Ministry of Inter-Provincial
Coordination notification, dated 14th October 2011. From that date until 30th June 2016, the NTP
functioned as a National Programme. Then, a joint PC-1 was approved for the period 1st July 2016 to
30th June 2019, extended until June 2020, to create the Common Management Unit (CMU) to
manage Global Fund grants for AIDS, TB and malaria. However, formally, the CMU was not
established under one roof until 1st January 2018 with the start of the 2nd tranche of the new funding
model (NFM-2) grant. Nominally, the NTP is a technical unit of the CMU, as are the National AIDS
Control Programme (NACP) and the Department of Malaria Control (DoMC). Global Fund-related
support functions like finance, PSM, audit, monitoring and evaluation, surveillance and research
were integrated for the three diseases. The NTP also functions as a subordinate department of the
MoNHSRC.
From the central level, the NTP collaborates with several technical and implementing partners,
notably the WHO, the US Agency for International Development (USAID), the International

24
Organisation for Migration (IOM), the National Rural Support Programme (NRSP), the Pakistan Chest
Society, the Pakistan Paediatric Association, Mercy Corps (and their partners, see below), Indus
Hospital Network (IHN – and their partners, see below)), the Aga Khan University (AKU), Green Star
Social Marketing, the Pakistan Anti TB Association (PATA) and other national NGOs.
Of particular relevance to this NSP, the NTP has taken some key steps for TB control:
 TB management information system: Integrated District Health Information System (DHIS-2)
for HIV, TB and Malaria has been developed and is expanding through the districts; the
majority of GeneXpert machines are connected by the automated GxAlert system; the NTP
carried out the first prevalence survey for TB conducted to current international standards
(2010-11), and the first drug resistance survey (DRS) in Pakistan:
 TB care provision: Provision of free anti-TB medicines at 5,000+ public sector health facilities;
provision of free diagnostics through 1,400 public sector facilities; 22 biosafety laboratories
for culture and DST (BSL2 & BSL3); established WHO recommended rapid testing (Xpert
testing) at 450 centres; 34 special centers for DR TB patient management; provision of social
support to all DR TB patients; guidelines and training material for patient management;
operational guidelines and training material to engage 5,000 private heath care providers for
TB management; TB awareness campaign through print and electronic media:
 TB Legislation: the NTP has assisted PTPs with developing and implementing “Mandatory TB
Case Notification” Bills, which have been passed by three Provincial Assemblies and bylaws
have been developed; pilot intervention for legislation for mandatory TB case notification;
however, the Bill in Balochistan and, notably, at Federal level is still in process;
 Research in TB: Capacity building in research workshops organized by the NTP has trained
researchers from all across the country and around 50 TB papers in national and international
journals have been published.
At federal level, the core responsibilities retained with the NTP, include strategic planning, formulation
of policy guidelines, technical support to the provincial/ regional programmes and other implementing
entities, disease surveillance and dissemination of data to national and international stakeholders,
monitoring and supervision of programme activities, coordination and communication with national
and international partners (bilateral and multi-lateral agencies and donors), and research and
development. The critical mass of TB experts is needed at the central level to carry out these fuctions.

Current staffing levels at the federal level of the NTP includes: 1 Deputy National Coordinator (DNC)
or NTP manager; 1TB advisor, 1 laboratory advisor,1 PPM focal person; 2 MDRTB specialists; . Only
six central unit professional staff for a population in excess of 200 million, with major coordination
challenges between provinces, regions and territories is short-sighted. While only the NTP Manager
is paid by the federal level, reluctance of external agencies to support more staff is understandable,
but this small number goes a long way to explain the poor level of grant disbursement (see 2.3.3).
Further challenges faced by the Central Unit in disease management and grant implementation
include:

 Adhoc management arrangements at federal level and HR limitations

 Coordination with the provinces for a coherent national response to disease control
 disease surveillance and international reporting
 Policy formulation for TB management
 Technical support to prepare TB management guidelines & training material for the country
uniform
 Development of the M&E framework and guidelines for the country
 Data analysis, evidence generation

25
  Research capacity building
 Gaps in multi-sectoral collaboration at all levels
 Absence of integrated disease surveillance system to timely pick unusual occurrence of cases
and respond efficiently
 Compromised M&E
 Limited domestic financing - government contribution is approximately 7% as health financing
is a provincial subject now
 Tax exemptions required for CESS, GST and Provincial Tax (Punjab)
 Collaboration with other health programs especially at implementation level
 Implementation of mandatory case notification law
Finally, confusions around the roles and responsibilities of the NTP and its staff after devolution, and
after the formation of the CMU, have not been entirely avoided.
Province and district level
There are regular coordination meetings at district and provincial levels where TB data is
examined, challenges identified, and corrective action proposed. These meetings (intra-district,
and inter-district at the provincial level) occur every quarter. However, regular inter-provincial level
meetings at the national level were no longer supported which was a cause for concern for the JPRM
in relation to national coordination of the TB response.

The PTP is part and parcel of the Department of Health structure at the provincial level and is
led by a senior member of the Provincial Health Team. However, while technical experts are
available, there has been a rapid turnover of program leadership in some provinces, affecting
programme performance, accountability and sustainability.
In the post-devolution scenario at provincial level, the Provincial TB Programmes had already
become sub-recipients (SRs) to the principal recipient (PR), the NTP, in a single stream funding (SSF)
grant which started on 1st January 2014. Until that point, the PTPs had worked as implementing
partners of the NTP-PR, just as AJK, GB and FATA implement grants nowadays.
At the district level, though, a multipurpose staff is normally the district focal person for TB, and
does not usually work full-time on TB, but can be pulled away for more priority issues, or those that
are attracting politicians’ attention. The post is not usually a regular position of the Ministry of
Health (Province) at that level.
In contrast, attempts have successfully been made to ensure that TB Basic Management Unit (BMU)/
RHC have staff responsible for TB activities. Thus, at the BMU/RHC a TB focal point who is a medical
officer, a Direct Observed Therapy Short course (DOTS) facilitator and laboratory technician
have been put in place in most provinces.
In general, the health sub- system below the level of the RHC is not currently involved in TB
services representing a lost opportunity to bring TB services closer to the community and people
affected by tuberculosis.
As for the private partners (see below - , by Round-6, in November 2007, Mercy Corps became the
private sector PR, along with NTP, as the public sector PR. IHN became an SR to NTP-PR in 2009 in
Round-9 of the Global Fund grant, and in May 2016, it was granted the status of second private
sector PR by the Global Fund, which continues to-date.
Organisation of TB Care services - Periphery
The 155 districts in Pakistan are the implementation units of the NTP/PTPs, and are responsible for
the care delivery processes including program planning, training of care providers, case detection,

26
case management, monitoring and supervision. The PTPs provides the districts with overall technical
and material support including drugs, lab supplies, hardware etc.. National numbers of diagnostic and
treatment services are shown in Table 7.
Table 7. Numbers of public and private diagnostic and treatment services, 2019

Public Private TOTAL

Diagnostic Services
Microscopy Laboratories 1,360 454 1,814
GeneXpert machines 334 34 368
Culture laboratories 18 04 22
Genotypic drug susceptibility testing 05 02 07
(DST) facilities – line probe assay (LPA)
Phenotypic DST 03 02 05
Digital X-Ray CAD4TB machines 09 52 61
Treatment Services
Basic Management units (BMU)*, 1,360 1,360
including (PPM 2,3,4 – see 2.4.4 for
explanation)
General Practitioners (PPM-1) 6,421 6,421
Programmatic management of drug 28 05 33
resistant TB treatment sites
HIV surveillance sites 40 40
*In addition to these, 15 Military hospitals are BMU as well.

The most peripheral elements of the NTP in the public sector are the BMUs, which cluster together
some 4-6 BHUs. However, in practice, the number of BHUs actively and formally engaged with the
PTPs is very small (Table 8). There is therefore concern that the engagement of the PTPs/RTPs and
NTP with the BHUs is insufficient, which was borne out by visits to BHUs by the JPRM members, and
the JPRM had made this point forcibly.

Table 8. Numbers of BHUs formally engaged with the RTP or PTP/NTP. Source: NTP

Province No. of BHUs Engaged Total No. of BHUs

Punjab 6 2500
Sindh 48 810
Balochistan 39 688
Khyber-Pakhtunkhwa 7 769
Azad Kashmir 12 227
Islamabad 3 16
Gilgit Baltistan 6 23
Khyber-Pakhtunkhwa (Tribal Districts) 3 169
Total 124 5202

Private sector PRs - Mercy Corps (MC)

Mercy Corps has been engaged in TB control interventions in Pakistan since 2002, and as the private
sector PR of the Global Fund to support TB control activities since 2007, initially implementing
Advocacy, Communication and Social Mobilization (ACSM) interventions in 57 districts of Pakistan. In
2010, MC started implementing Public-Private Mix (PPM) interventions to increase TB case detection
and to ensure that a standardized diagnosis and treatment process was provided to TB patients.

27
MC is currently implementing the current Global Fund grant in 67 districts across the country with the
support of six implementing partners, and is directly implementing itself in a few of the districts (Table
9). MC is currently using three different approaches to reach the missing TB cases and enhance TB
case notification. These approaches include; a) GP Model, b) active case finding and c) enhanced case
finding. Through all these interventions, MC was able to register over 55,000 TB cases, all forms, since
January 2018, with a treatment success rate of 94% (Table 10). A total of 289 rifampicin resistant (RR)
cases were also notified. Overall, the PPM contribution in the districts in which MC in working
increased from 8% in 2015 to 24% in 2018.

The interventions are as follows:

Engagement of private healthcare providers and labs (the GP model)

1. Mapping and selection
2. Training
3. Provision of anti-TB drugs, lab reagents and other consumables
4. Data recording and reporting, supervision and monitoring

Active case finding

1. Community gatherings
2. Engagement of Lady Health Workers
3. Conventional chest camps
4. Mobile screening camps with digital x-rays and Gene Xpert

Enhanced case finding

1. TB screeners in large private hospitals
2. GeneXpert testing
Table 9. Sub-recipients and their geographical coverage. Source: Mercy Corps

Sub Recipients Province No. of

Districts

1 Association for Community Development (ACD) Khyber Pakhtunkhwa 12

2 Association for Social Development (ASD) Punjab 13
3 Bridge Consultants Foundation (BCF) Sindh 11
4 Pakistan Lions Youth Council (PLYC) Punjab + Sindh 4+4
5 Strengthening Participatory Organization (SPO) Balochistan 6
6 Marie Adelaide Leprosy Centre (MALC) Azad Jammu & Kashmir; 7
Gilgit-Baltistan,
7 Mercy Corps Project Implementation Unit (PIU) Punjab 7
8 Mercy Corps – Quetta Balochistan 3
Total 67

28
Table 10. Intervention wise progress. Source: Mercy Corps

Targets of cases from chest camps and LHWs component were not met because of delayed initiation
of the interventions as well as temporary halts due to reasons beyond MC’s control.
Indus Health Network (IHN) as PR
Under their Zero TB – Search, Treat, Prevent - model, IHN conducts three main activities:

Active case-finding in adults

Facility - Based Screening model: Active Case Finding (ACF) among adults is conducted through
digital chest x-rays using computer-aided detection- CAD4TB technology for identification of
presumptive TB and access to GeneXpert Testing (at baseline) of all presumptive TB. This
intervention engages with health facilities across the intervention city, screening all individuals
coming in to hospital OPDs as well as in-patient departments (where the program is operational).
Screening camps are also conducted in the catchment populations of these hospitals

Community Screening model: A significant proportion are missed in the community. The program
conducts community based screening (along with private partners) in high-burden areas identified as
hot-spots for disease and amongst high-risk groups/populations in districts where the program is
operational.

Contact management and prevention treatment

Facility-Based contact screening: The program reaches out to the families of TB patients and invites
them in health facilities for TB disease evaluation. All contacts are thoroughly screened for TB by a
doctor. All those diagnosed with TB are started on TB disease treatment. All household contacts who
are free of TB disease are eligible for TB prevention treatment. The intervention offers preventive
treatment to all the household contacts ensuring completion rate of at least 65%.

Targeted community based contact screening to improve access and coverage of services: Household
contacts of TB patients are mostly healthy individuals having no symptoms. It is difficult to convince
them to visit health facilities for screening as that is time consuming and most of the families are
from working class earning their wages on a daily basis. Visiting facility means compromising their

29
daily wage. This allows for provision of services near their doorstep maximizing numbers of contacts
screened.

Active case finding in children

Screening of children visiting pediatric OPDs (at the health facilities where the program is active) is
conducted using a dedicated nurse trained on a verbal symptom screen tool for TB and with
assessment of risk factors such as presence of TB contact and/or TB history. Those identified as TB
presumptives are referred to a trained medical officer who further evaluates the children for TB and
confirms TB diagnosis. Patients identified with TB are started on treatment and followed through
their course of treatment to ensure adherence and favorable treatment outcomes.

Table 11. Results summary by partner for 2018 to end of quarter 3, 2019. Source: IHN

Jan – Jun Jul – Dec Jan – Jun Jul-Sep

Activities Program/SRs 2018 2018 2019 2019 Total

GSM GPs (SR) 14,364 14,448 13,493 7,300 49,605

CHS Centers (SR) 5,280 6,587 7,612 4,664 24,143

Indus Hospital
1105 838 877 385 3,205
site (PR)

DSTB Cases Notified

Zero TB
(New and Relapse)
Intervention 519 820 1,041 510 2,890
Private sites (PR)

Zero TB
Intervention 4,970 5,813 6,267 2,924 19,974
Public sites (PR)

Total TIH 26,238 28,506 29,290 15,783 99,817

GSM (SR) 88% 92% 89% 86%

DSTB Cases CHS (SR) 80% 72% 79% 80%

Treatment Outcomes Indus (PR) 88% 82% 91% 91%
Total TIH 86% 87% 87% 86% 87%

Conventional Chest Camps GSM (SR) 621 521 662 338 2,142

X Ray Van Camps

CHS (SR) 1130 1344 1,062 4,249
(Community Based)
713

X Ray Vans Camps

(Community and Health Indus (PR) 984 1866 2,603 1246 6,699
Facilities Based )

30
 Total TIH 2,735 3,731 4,327 2,297 13,090

CHS (SR) 31 60 23 114

0
DS TB cases (N+R) notified
among prisoners (Jail Indus (PR) 11 4 3 0 18
Screening Output)

Total TIH 42 64 26 0 132

GSM GPs (SR) 35 40 35 23 133

CHS Centers (SR) 98 97 91 52 338

Indus Hospital
DR TB Cases Notified 36 25 38 14 113
site (PR)
(Detected and Enrolled)
Zero TB
Intervention 57 51 55 39 202
sites (PR)

Total TIH 226 213 219 128 786

TB cases with RR TB and/or PMDT (PR) 650 615 570 251 2,086
MDR - TB that began on
Second line treatment
(Enrolled) Total TIH 650 615 570 251 2,086

IHN, CHS, GSM and MC all invest considerable resources in a variety of mass screening camps, often
with digital x-ray and Xpert, at hospitals, outside GP clinics, or in communities and worksites. In
2018, the three main NGOs operated 27 x-ray vans (some of which also have Xpert), conducted
4,667 screening camps of various kinds, and found 5,838 cases (an average of 1.25 per camp)
through this approach. Even assuming an average of just 15 cases per GP per year (the average
is 23 under PPM1), this same number of cases could be generated by engaging an additional 397
GPs; assuming the current staffing pattern of 1 field officer per 15 GPs, this could be achieved with
26 field officers which is a third of the staff required for the 27 vans alone, and many more are
needed for the conventional camps.
The NTP has recently begun to strengthen partnerships, through provision of training, drugs,
diagnostics, recording and reporting tools supervision to the Agha Khan Development Network,
which operates over 450 clinics, 5 secondary hospitals, and the flagship Agha Khan University
Hospital (AKUH) in Karachi, and 15 major Military Hospitals. Both partnerships seem to have the
potential to contribute substantially to TB case notification from 2019, if properly managed.

31
2.3.2 Current epidemiological status36
Tuberculosis may have dropped down the ranking of those diseases and conditions that cause most
deaths, but in 2017, TB remained the 9th most important cause of death in Pakistan, and the most
lethal infectious disease (Figure 5).

Figure 5. The top ten causes of death in Pakistan, 2007 and 2017. Source: IHME, Seattle, USA.

In 2018, WHO estimated that 562,000 people developed TB, at a rate of 265/100,000 population per
year, and 43,000, or one in twelve, died from it. In addition, 28,000 cases of rifampicin resistant (RR)
or MDR-TB developed that year. The WHO estimates that the incidence of TB is falling gently (Figure
6), but the rate of fall is exceeded by population growth, and therefore there are more cases
occurring each year.

Notifications rose 22% between 2012 and 2017 as coverage of national TB efforts increased, but fell
slightly thereafter. In 2018, 369,548 cases were notified, about 650 more than in 2017, but (because
of population growth) this represents an important fall in case detection rate from 68% to 64%.

Alarmingly, the first two quarters of 2019 have seen a significant (9.5%) fall from the same quarters
in 2018 – 189,849 compared to 171,307 in 2019. The reduction was greatest in the Punjab, but was
also seen in AJK, FATA, GB, KP and Sindh. Case detection is therefore falling, both in absolute
numbers, and also in incidence rate, suggesting that there are significant problems with the anti-TB
efforts in Pakistan.

Figure 6. Tuberculosis epidemic profile, 2000-2018. Source: WHO, Global Control Report

36
Data from the WHO 2019 Global TB Control Report, unless otherwise stated.

32
Nationally in 2018, 80% of all notified cases were pulmonary, and 20% were extra-pulmonary TB
(EPTB). Of the pulmonary cases, 48% were bacteriologically confirmed, as a result of the steady
increase in this category over the years, probably due to the availability of GeneXpert testing. Extra-
pulmonary cases appeared extraordinarily high in ICT, KP and FATA at 51%, 38% and 34%,
respectively, in 2017, which is probably due to the high prevalence of tertiary hospitals in ICT, which
have facilities to diagnose EPTB, as well as the fact that the more rural and pastoral areas globally
tend to produce more EPTB.

Since 2015, there has been a significant increase in the proportion of cases found through
collaboration with the private sector (Figure 7), especially those cases found by private general
practitioners (GPs) who contributed about 17% of the total cases in 2018, while the PPM private
sector as a whole contributed 32% of total cases. This is discussed in more detail in section 2.4.4 and
Table 17, but also of note is that the proportion of bacteriologically confirmed cases is significantly
higher in the public sector than in the private sector (Table 12). This is probably due to greater use
of radiology in the private sector, and especially the use of computer-aided diagnosis (CAD4-TB), and
the readiness on the part of private physicians to make a diagnosis on the basis of radiological
findings alone. Simply changing the sensitivity in the CAD4-TB system can alter the rate of clinical
diagnoses which may assist in achieving the targets in the private sector, but it may encourage the
diagnosis of TB in patients without the disease.

Figure 7. Case notifications from non-NTP/PTP sources (PPM models – see 2.4.4) 2015-2018.
Source: NTP data

33
Table 12. Proportions of different TB case types deriving from public and private sector case-
finding. Source: NTP.

The RR/MDR-TB cases arise in 4.2% of the new cases, and 16% of the retreated cases37. In 2018,
however, only 3,824 cases were diagnosed and 3,106, or 11% of the total estimated incidence, were
started on treatment. At first sight these figures suggest a massive gap between the numbers of
cases estimated (43,000), and those treated but, effectively, this is not quite as serious as it seems:
RR/MDR-TB cannot be diagnosed unless it is bacteriologically confirmed. Therefore, if we apply the
same proportion of 38% of all cases of all types being bacteriologically confirmed to the estimated
number of RR/MDR-TB cases, this is about 16,500. RR/MDR-TB case finding is therefore 23% of the
bacteriologically confirmed. Ninety-five cases of XDR-TB were also diagnosed and 71 of these started
treatment.

Treatment success rates fell with increasing levels of resistance (Table 13) but there were no data on
the outcomes of patients with HIV-associated TB.

Table 13. Treatment success rates reported to WHO for the 2019. Source: WHO 2019 Global TB
Control Report

In 2017, 7,300 cases of TB were estimated to have occurred in Pakistan, but HIV testing was only
done in xx% and 121 cases were diagnosed. By 2018, HIV testing had increased significantly and 636
cases of TB with HIV infection were diagnosed, of whom 66% were started on anti-retroviral
treatment.

Children (less than 15 years of age) constitute about 11% of all incident cases, and 13% of all notified
cases. However, the proportions of all TB that are in children are much higher in FATA, GB and KP
(28.4%, 41.2% and 29.7%, respectively) than elsewhere in Pakistan. In many cases, these appear to
be over-diagnosis of abdominal TB on the part of a limited number of practitioners38. Of the
household contacts less than 5 years of age, only 5.7% were started on preventive therapy in 2018.

37
NTP. Drug resistance survey, 2011.
38
Dr Sabira’s data

34
Drivers of the TB epidemic
Age, male sex, undernutrition, smoking, diabetes mellitus and HIV are the main specific drivers of TB
in Pakistan, leaving aside poverty in general.

TB notifications generally increase with age in high prevalence areas. In the oldest ages a drop-off of
notification is sometimes observed, but this is most likely due to reduced access to care among the
most elderly.

The sex ratio among notified cases in Pakistan in 2018 was 1.3 males to each female, which is rather
less than the 1.78 adult men to 1 woman reported globally for 201836 (with 1.1 million children, sex
undefined).

Four in ten under five children are stunted39. A 2019 national survey showed a 4 per cent decrease
since the last survey conducted in 2011, and that nearly two out of every ten children under five also
suffered from wasting. Boys suffer disproportionately: one in every eight adolescent girls and one in
every five adolescent boys suffers from being underweight. Over half of the adolescent girls in
Pakistan are anaemic. The highest rates of malnutrition are seen in Balochistan .

Smoking is known to at least double the risk of TB. “Based on the World Health Organization’s 2013
standardized estimate of smoking prevalence, 31.8 % of men, 5.8 % of women, and 19.1% of
Pakistan’s adult population currently use tobacco in one form or another. Of these, 17.9 % of men, 1
% of women and 9.6 % of the adult population overall are daily cigarette smokers, while 4.4 % men,
1 % women and 2.7 % of the adult population are daily water pipe smokers. Moreover, 10.5 % men,
3.5 % women and 7.1 % of adults use smokeless tobacco daily. Among the youth, 13.3 % of boys, 6.6
% of girls and 10.7 % of all youth currently use tobacco or a tobacco product.”40

Diabetes mellitus increases the risk of TB between 2- and 3-fold41. Of nearly 20,000 participants
above the age of 20 years in a recent study using HbA1c levels42, the prevalence of prediabetes was
a frightening 11%, and of type 2 diabetes was 17%, with both associated with female sex, older age,
a family history, rising body mass index, and central obesity, and inversely associated with level of
education. A 2016 meta-analysis of 22 studies43 gave a slightly lower figure of 11.77%. The
prevalence was higher in males than females and more common in urban areas compared to the
rural areas.

Pakistan is, in general, a low-incidence HIV country, but it has a significant, and rising, concentrated
epidemic of HIV. While general population rates are below 0.1%, this still represents about 165,000
people with HIV/AIDS (PLHIV) with an estimated 20,000 new infections annually, of which only 6,000
are diagnosed. Antiretroviral treatment, however, is only being provided to 18,000 cases.
Physicians are reluctant to start treatment early in spite of clear international evidence.

39
MOHNSRC. National Nutrition Survey (NNS), 2019.
40
Tobacco Free Initiative. Tobacco control in Pakistan.
https://www.who.int/tobacco/about/partners/bloomberg/pak/en/ Accessed 11 December, 2019.
41
WHO, 2011. Collaborative framework for care and control of tuberculosis and diabetes. WHO, Geneva.
42
Aamir AH, Ul-Haq Z, Mahar SA, et al. Diabetes Prevalence Survey of Pakistan (DPS-PAK): prevalence of type 2
diabetes mellitus and prediabetes using HbA1c: a population-based survey from Pakistan. BMJ Open
2019;9:e025300. doi:10.1136/ bmjopen-2018-025300
43
Sultan Ayoub Meo et al. Systematic Review: Type 2 diabetes mellitus in Pakistan: Current prevalence and
future forecast. J Pakistan Med Assoc, December 2016, Volume 66, Issue 12.

35
Among people who inject drugs (PWID) HIV prevalence is 38%, transgender 7%, female sex workers
(FSW), 2.2% and men who have sex with men (MSM) 5.4%44. Levels are rising at the fastest rates
among the MSM and FSW. These results were from a survey carried out only in the large provinces.

Among TB patients in a large cross-sectional study performed in 2013-2015, 145 (0.66%) patients
were found HIV reactive45. The prevalence of HIV was higher (1.02%) in extra-pulmonary and male
TB patients (1.23 %) as compared to pulmonary (0.55%) and female patients (0.09%). Massive
outbreaks of HIV due to poor injection practices have recently been reported in Pakistan. Among
1,150 cases, mainly children, detected in Larkana, in 2019, 13 were diagnosed with TB46. Of the
12,000 PLHIV in Sindh, 92 are known to have contracted TB. The prevalence of TB in HIV-infected
injectable drug users is estimated to be fifteen times higher compared to the general population47.

TB screening is carried out at baseline and most subsequent visits of PLHIV to the HIV Clinics, using a
four-symptom screen. IPT is not often given and about 50% of known PLHIV are thought to have
been treated. Physicians are reluctant to prescribe it for fear of anti TB drug resistance. Although
PLHIV are eligible for MTB/RIF-Xpert testing, this is not regularly performed.

There are no records of HIV-associated MDR-TB outbreaks and HIV rates in MDR-TB patients have
been very low to date, but HIV-associated MDR-TB outbreaks are probably a disaster waiting to
happen.

2.3.3 TB Programme Funding

Government

Government funding for the TB NSP 2017-2020 was about US$ 34 million or 7% of the total request
(see Section 1.3.3). Government funds come through the Annual Development Program (ADP),
managed by the Provincial Planning Commissions (PC), and this is the main mode of mobilizing
resources from the Government for TB activities in the provinces – the so-called PC-1 funding
mechanism. It is a project-based mechanism in which funds are approved in principle but released
subject to availability, typically only partially and after delays. Over the last three years, only 48%,
43% and 51% of allocated funds for TB have been released (Figure 8).

The ADP funds do not include staff salaries and infrastructure costs which are covered in the
provincial and regional regular budgets. The Sindh Provincial Government has agreed in principle to
move TB funding to the regular (SNE) budget from FY 2019-20, which should significantly increase
both the amount of funding for TB and the reliability with which it is released to the Program.

44
National AIDS Control Program, Pakistan. Integrated behavioural and biological survey, 2016-2017.
https://www.nacp.gov.pk/repository/whatwedo/surveillance/Final%20IBBS%20Report%20Round%205.pdf
Accessed 11 December 2019.
45
Muhammad Aamir Safdar, Razia Fatima,Nasir Mahmood Khan et al. Prevalence of Human Immune
Deficiency among Registered Tuberculosis Patients across Pakistan during 2013-2015 —Prevalence of TB-HIV
Co-Infection in Pakistan. Journal of Tuberculosis Research, 2018, 6, 96-103 http://www.scirp.org/journal/jtr
ISSN Online: 2329-8448 ISSN Print: 2329-843X DOI: 10.4236/jtr.2018.61009 Mar. 27, 2018.
46
NACP. Personal communication, October, 2019.
47
Tahseen S, Shahnawaz H, Riaz U, Khanzada FM, Hussain A, Aslam W, von Euler-Chelpin M. Systematic case
finding for tuberculosis in HIV-infected people who inject drugs: experience from Pakistan. Int J Tuberc Lung
Dis. 2018 Feb 1;22(2):187-193. doi: 10.5588/ijtld.17.0390. PubMed PMID: 29506615

36
Figure 8. PC-1 funding, in US$, for the financial years, 2015-16, 2016-17 and 2017-18. Budgeted in
green bars, released in brown, and disbursed in blue. Source: JPRM 2019.

Global Fund
In the current grant cycle (2018-2020), the Global Fund originally promised US$ 144 million
distributed among three Principal Recipients (PRs) to cover the Global Fund’s modules: TB care and
prevention, MDRTB, TB/HIV, Building Resilient and Sustainable Systems for Health (RSSH) and
program management. Of the 144 million US$, the GoP through the Central Management Unit and
the National TB Programme, as the Government PR, was allocated US$ 89 million (61% of the
available GF financial resources for TB in Pakistan), Indus Hospital Health Network (IHN) US$ 40
million (27%) and Mercy Corps US$ 15million (10%).
In a special agreement with the Global Fund, additional resources were provided for the
procurement of GeneXpert machines and cartridges in 2016-2017, which brought the total
contribution up to US$ 148 million (Tables 14 and 15).
For the 2016-17 period, there was a significant underspend of 11%, or US$ 9.86 million, that was
returned to the donor. A similar underspend looks likely for 2018-19, with only one eighth of the
grant period still unreported. The under-spend is across all categories of spending, except for
procurement costs. The disbursements for drugs and other commodities will be reduced by the
failure to reach case-finding targets. Of note is the dismal 17% for the living support costs for MDR-
TB patients and families. It is a relatively small amount of total funding, but is desperately needed
by the affected families. In a country desperate for resources and with minimal federal level
support, this funding absorption failure suggests major problems of management and organisation.
The TB Global Fund grant in Pakistan is achieving the intended results, just, with a rating of B1.

Table 14. Budget v actual expenditure, July 2016- December 2017

Burn
Budget Actual Variance Rate

1. Human Resources (HR) 15,795,644.24 11,187,173.73 4,608,470.51 71%

2. Travel related costs (TRC) 7,113,455.57 4,121,641.28 2,991,814.28 58%

3. External Professional services (EPS) 381,432.23 137,529.84 243,902.39 36%

37
 4. Health Products - Pharmaceutical Products
(HPPP) 19,718,733.48 22,708,539.16 (2,989,805.68) 115%
5. Health Products - Non-Pharmaceuticals
(HPNP) 13,231,636.50 4,073,551.96 9,158,084.54 31%

6. Health Products - Equipment (HPE) 6,379,905.58 19,187,388.43 (12,807,482.85) 301%

7. Procurement and Supply-Chain Management
costs (PSM) 6,388,113.11 4,657,306.89 1,730,806.22 73%

8. Infrastructure (INF) 1,891,785.69 957,364.36 934,421.33 51%

9. Non-health equipment (NHP) 1,891,508.86 639,584.56 1,251,924.30 34%

10. Communication Material and Publications
(CMP) 1,296,193.97 530,198.48 765,995.50 41%

11. Programme Administration costs (PA) 1,968,448.13 1,152,624.26 815,823.87 59%

12. Living support to client/ target population
(LSCTP) 5,589,248.31 3,276,764.23 2,312,484.08 59%

TOTAL 81,646,105.68 72,629,667.19 9,016,438.49 89%

Table 15. Budget for January 2018 to December 2019, Actual expenditure to end Q3 2019.

Budget Actual Variance

1. Human Resources (HR) 12,001,662.14 7,592,958.44 4,408,703.70 63%

2. Travel related costs (TRC) 4,303,280.18 2,103,339.97 2,199,940.21 49%

3. External Professional services (EPS) 155,444.16 102,209.18 53,234.98 66%

4. Health Products - Pharmaceutical Products
(HPPP) 34,390,071.18 23,375,474.44 11,014,596.74 68%

5. Health Products - Non-Pharmaceuticals (HPNP) 1,913,153.33 942,974.22 970,179.11 49%

6. Health Products - Equipment (HPE) 4,823,360.50 3,224,425.06 1,598,935.44 67%

7. Procurement and Supply-Chain Management
costs (PSM) 5,770,205.61 5,867,582.52 (97,376.91) 102%

8. Infrastructure (INF) 70,861.06 50,573.31 20,287.75 71%

9. Non-health equipment (NHP) 134,064.40 69,615.48 64,448.92 52%

10. Communication Material and Publications
(CMP) 107,359.74 83,998.16 23,361.58 78%

11. Programme Administration costs (PA) 798,484.17 464,863.18 333,620.99 58%

12. Living support to client/ target population
(LSCTP) 1,922,219.52 326,748.54 1,595,470.98 17%

TOTAL 66,390,166.00 44,204,762.51 22,185,403.50 67%

38
2.4 TB service components
2.4.1 Case identification and diagnosis - drug susceptible TB
The problem
In a nutshell, case finding is falling, when it should be rising (Section 2.3.2). While there have been
notable successes in recent years in finding children with TB, and in getting GPs to diagnose and
notify cases of TB, the overall efforts, particularly in the Punjab, have not been enough to find more
than 74% of estimated incidence.

The JPRM was very clear that the peripheral parts of the health system were unengaged in TB case
detection: “Most of them, except for a very few dispensaries and BHUs in Punjab and Sindh
Provinces, have not yet been involved in the process of TB case-finding among patients who seek
care. The health staff of these PHC facilities have not been trained and involved in the identification
and registration of presumed TB patients or in collecting samples from them for laboratory testing.
Most of the presumed TB patients who seek care in the BMUs, visited during the review, do not do
so following health provider-initiated screening and referral from a PHC level; they are usually
self-referred (patient-initiated pathway). This suggests that the process of TB case-finding is not
taking place in the existing PHC network in Pakistan. In addition, the staff of the dispensaries and
BHUs have no information on, nor are they engaged in, the management of the TB patient living in
their catchment areas who are treated and followed by the BMUs.”
In Sindh Province, however, it was observed that BHUs, whose staff were trained on the
identification of presumed TB and linked to the relevant BMUs, were able to identify patients with
TB signs and symptoms, use the register of presumed TB cases and refer them to the closest BMUs.
This experience strongly suggests that the involvement of PHC facilities is feasible. The great number
of such health facilities (> 11,000) which have not yet been involved in TB services provision
constitutes a major asset for TB case-finding in Pakistan. Similar observations were made of staff in
the OPDs of large hospitals.
The JPRM also observed that the majority of physicians had not been trained in TB case
identification, follow up, management, or the guidelines of the NTP. Lack of funds had prevented
any significant amounts of training of physicians and other staff after 2016. Very few facilities had
NTP guidelines, algorithms, desk aids or wall charts, available to the clinicians.
Contact screening and examination is a significant, if relatively small, source of cases in most
programmes, but in Pakistan, NTP data collected routinely in 2015 to 2017 show that:

 approximately 10% of the identified contacts are screened for TB,

 2 to 4% of the screened contacts had active TB, and
 contact investigation contributed to hardly 1% of TB notifications.
The immediate causes for this neglect of a basic public health duty appear to be guidelines that do
not reflect recent (or even old) WHO recommendations, a failure to use the guidelines, an absence
of guidelines and training materials in health facilities, and a lack of training of frontline doctors and
nurses on this topic. What is more, the emphasis placed by the UNHLM on increasing preventive
treatment has significantly increased the targets for preventive therapy for all countries, and, for the
first time, strongly emphasised the need to treat contacts over the age of 5 years.

Various approaches were included in the NSP, 2017 including the involvement of lady health workers
(LHWs), but this was mainly for the organisation of screening camps and treatment support, rather
than finding cases in the community through their normal daily rounds. Since then, LHW
engagement in 3 remote districts of Sindh suggests there is untapped potential to use LHWs to find

39
additional TB cases48. However, the June 2019 inter-ministerial meeting raised the issue of
“financing the vertical programs especially the Lady Health Worker (LHW) Program. The program has
been regularized, salaries are being paid but lacks the funds for operational (sic). … Minister Health
Punjab mentioned that LHW are too occupied with various other tasks that they fail to do their
original designated tasks. Minister Health Sindh endorsed this point. It was suggested that LHWs are
very important workforce and need to ensure national coordination. The Federal Government
should take the ownership and provide the financial support to the province. “

The conclusion is that any approach to the LHWs has to be a) done in full coordination with the
managers of the LHW programme, province by province, and b) fully funded, if there is to be a
chance of success.

Data from the private sector show that this sector has significantly contributed to case finding in
recent years, and also that there is large, untapped potential to increase this contribution, especially
through the GPs. This will be addressed in detail in section 2.4.4.

Furthermore, the currently used diagnostic algorithm, especially in the public sector, still largely
relies on symptom screening and sputum smear microscopy (Figure 9). It is therefore too
insensitive, yet technologies exist that have been proven to be more sensitive. The most important
of these is the GeneXpert MTB-RIF test. However, its use has been largely confined to universal
testing of sputum smear positive cases for drug susceptibility testing, rather than using the
technology for case finding. Exceptions were those at high risk of MDR-TB, PLHIV, and children.

48
Mercy Corps report. 806 LHWs screened 544,717 individuals for symptoms of TB during a one year project
implementation and identified 7,698 individuals with symptoms, 83% of whom reached a healthcare facility
for testing. Of the individuals tested, 18% were diagnosed with TB and registered for treatment – 463
bacteriologically confirmed and 702 (60%) clinically diagnosed. This constitutes 0.2% of the entire population.
Compared over time, there was a 5% increase in case notification in the intervention districts, while the
control districts experienced a 13% decrease. The intervention included verbal screening during household
visits by LHWs, outreach chest camps and contact screening during household visits by LHWs. Each LHW was
give around US $10 for a registered case. The treatment delay was shown to be significantly reduced
compared to case finding by private practitioners.

40
Figure 9. Diagnostic algorithm of NTP, Pakistan. Source: NTP National TB Guidelines, 2019

2.4.2 Programmatic Management of Drug Resistant TB (PMDT)

The number of RR cases enrolled onto treatment has stagnated since 2016, despite a rapid increase
in Xpert testing, (see next section 2.4.3). There are 33 PMDT sites for 155 districts and the number
of PMDT treatment sites has not increased in recent years. The treatment success rate among RR-TB
patients has declined gradually from over 70% in the early years of the program to 62% in the 2016
cohort, mainly because of increasing deaths and patients lost to follow-up. The deaths are probably
mainly caused by patients being diagnosed with TB very late, having spent many months in the
health services before being diagnosed with TB, and less in delay in diagnosis and treatment of DR-
TB.
Most PMDT sites are separate units inside public tertiary hospitals, administered by partners and
funded by the Global Fund. This raises sustainability concerns and has not contributed to a sense of
ownership by the PTPs. Long distances and high travel cost for patients to come for monthly
evaluations and medicine supplies have contributed to high levels of patients lost to follow-up which
is compounded by the weak link between PMDT sites, district TB programs and BMUs. Treatment
supporters are mainly family members.
The rate of resistance to the most important second-line drug (SLD) family, the fluoroquinolones
(FQs), is around 40% in RR -TB patients in Pakistan - very high compared to other countries. And
resistance to one of the new drugs, bedaquiline, is increasing around the world, including in

41
Pakistan: among 98 RR patients started on BDQ-containing regimens, 9 have failed, and 7 developed
BDQ resistance49.
The 2019 ATS/CDC/IDSA guidelines now recommend the use of bedaquiline in routine MDR-TB
treatment and enable the choice of an all-oral regimen for the treatment of MDR-TB. Rapid advice
from WHO in December 2019 has mostly followed suit and now recommends that a “shorter, all-
oral, bedaquiline-containing regimen may be used instead of the standardized shorter regimen with
an injectable.50” In addition, a green light has been given to the 3 drug 6-9 month course of
bedaquiline, pretomanid and linezolid under “operational research conditions”. Further
developments can be expected to occur rapidly in the coming months and years. The NTP/PTP will
need to be on top of them.

2.4.3 Laboratory network

Background
The TB laboratory network Pakistan is arranged in four tiers: national, provincial, district and
peripheral. Across the country there are more than 1,313 health facilities and 420 private laboratories
providing microscopy facilities. GeneXpert rollout started immediately after the endorsement of WHO
in 2010 and by December 2018, 303 facilities were equipped with GeneXpert and all districts now have
access.
Provincial reference laboratories are functioning in each of the four provinces, with two in Punjab,
providing DST services for patients enrolled in the PMDT program. These laboratories have facilities
for automated liquid culture and rapid molecular DST for first and second line DST (line probe assay
(LPA)). Beside these reference laboratories, 15 culture laboratories are established at sub-provincial
level to provide services for monitoring the response to treatment of DR-TB patients. There are two
TB laboratories having DST capacity in the private sector both located in Karachi – the Indus and AKU
hospitals.
AFB microscopy still remains the first line diagnostic test for most presumptive cases seeking care due
to low coverage of Xpert, and weak or negligible specimen transport systems. This is in spite of the
three- fold increase in Xpert machines from 100 in 2017, to 303 by the end of 2018 (Figure 10). The
diagnostic guidelines have now been updated and upfront testing is recommended for all presumptive
TB cases having an abnormal CXR, a high risk of MDR, children, the immunocompromised, and EPTB
cases where a suitable specimen can be obtained. However, these new guidelines are not yet fully
implemented.

49
Ghodousi A, Rizvi AH, Baloch AQ, Ghafoor A, Khanzada FM, Qadir M, Borroni E, Trovato A, Tahseen S, Cirillo
DM. Acquisition of cross-resistance to Bedaquiline and Clofazimine following treatment for Tuberculosis in
Pakistan. Antimicrob Agents Chemother. 2019 Jul 1;. doi: 10.1128/AAC.00915-19. [Epub ahead of
print] PubMed PMID: 31262765.
50
WHO, 2019. Rapid Communication: Key changes to the treatment of drug-resistant tuberculosis.

42
Figure 10. Numbers of MTB-RIF (GeneXpert) tests carried out 2011-2019 (quarter 2), with numbers
of cases of TB and rifampicin resistance (RR) detected. Source: NTRL

400000 4500
Test MTB RR 350457
350000 4000
3824
280049 3475 3500
300000 3331
3019 2971 3000
250000 226968
2500
200000
1921 2000
150000 1662 1764 127791
1500
90635
100000 72681 1000
56252 54991
35984 43167
50000 17026 18965 22832 500
14862
9464 8473
914
571187
0 0

All patients detected as RR are referred to PMDT sites. A reasonably effective transport mechanism
exists between current PMDT sites and Culture/DST laboratories, where rapid DST is performed for
first and second line drugs (rifampicin, isoniazid, fluoroquinolones and injectables) and culture is
processed. Phenotypic DST is performed for FLD and SLD.
Problems

 There is a very limited access to MTB-RIF testing for people seeking health care
from facilities not equipped with Genexpert – which is about 70% of all facilities and 40% of
patients. An effective and robust specimen transport system for transport of specimens
from most peripheral health facilities (or communities) to the nearest health facility with
Xpert testing facilities is therefore essential.
 In some places scale up of Xpert to the sub-district level, provided the infrastructure is good
enough to support its functioning, will be appropriate.
 Conventional CXR is available at most of the health facilities but machines are often old and
produce suboptimal quality Xrays. They are not usually available free of cost to the patient.
This is not a viable option for screening of all presumptive cases.
 Digital CXR facilities are limited, and usually employed to offer free services only in chest
camps or other active case finding activities. Therefore, provision of digital Xray machines to
health facilities with high OPD patient volumes is required.
 Due to current limited DST capacity, services are not offered systematically to all previously
treated rifampicin sensitive TB patients for susceptibility testing to other first line drugs.
With planned scale up of PMDT care, well-trained human resources, uninterrupted supplies,
well-maintained (additional) equipment and laboratories, QA, and a transport system linking
to all the district DRTB sites will be required for culture and DST laboratories.
 Additional culture laboratories with capacity to perform LPA will be required for provinces
where disease burden is high and coverage is low.

43
  National TB Reference Laboratory : To continue its current role with regard to provision of
mycobacteriology services, capacity development, quality assurance, research and technical
assistance for scale of QA laboratory services at country level;
 Surveillance of drug resistance: There is high fluoroquinolone resistance in Pakistan51and new
and repurposed drugs (Bedaquiline, delamanid, clofazimine, and maybe, in the future,
pretomanid) will now be used for treatment of DR-TB. Ongoing surveillance for emerging drug
resistance to new drugs needs to be strengthened, with capacity for whole genome
sequencing in collaboration with established collaborating partners at national (AKU) and
international level(SRL-Milan and Antwerp).

2.4.4 Engaging all care providers - Public-Private Mix (PPM)

The problem
In Pakistan, an estimated 84% of initial healthcare seeking is estimated to take place in the private
sector: 24% with informal providers and 61% with formal providers, especially GPs52. Private
healthcare providers include at least 100,000 GPs, over 67,000
Table 16. Proportion of estimated private
pharmacies, thousands of laboratories, and around 5,000
healthcare providers actively engaged in
hospitals (Table 16). While they are concentrated in urban
PPM, 2018
areas, GPs and informal providers also serve small towns in
rural areas. Estimated Actively % Actively
Type total number engaged engaged
Using pharmaceutical market research data, the volume of
Pharmacies 67,000 1,000 1%
anti-TB drugs sold in the private market in Pakistan was
GPs 100,000 4,207 4%
estimated to be equivalent to 265,850 patients in 2008 and
Labs n/a 431 n/a
272,135 in 201553. The market leader is Myrin-P54, sold in FDC
Subtotal primary 167,000 5,638 3%
formats, with a full 6-month treatment course costing a total
of around Rs 6,000 (US$ 39) for the average adult. Hospitals 5,000 167 3%

There are four main models of Public-Private Mix for TB PM in Pakistan: PPM1 for GPs, PPM2 for
NGOs, PPM3 for private hospitals, and PPM4 for parastatal or other public hospitals. The total number
of TB case notifications from PPM increased from 58,288 (20% of the total) in 2013 to 119,814 (32%
of the total) in 2018 (Table 17). The biggest increases have come from the GPs since 2016. Still, less
than 5% of private primary care providers are actively engaged with the NTP, and some large public
and private hospitals are not screening for TB in OPD and nor are they effectively linked with NTPs or
PTPs.

51
Zignol M, Dean AS, Alikhanova N, et al. Population-based resistance of Mycobacterium tuberculosis isolates
to pyrazinamide and fluoroquinolones: results from a multicountry surveillance project. Lancet Infect Dis. 2016
Oct;16(10):1185-1192.
52 Patient Pathway Analysis; Report of National Workshop on Data and Evidence for Policy Actions Towards

Ending TB in Pakistan; Jan 2019

53
Wells (2011), Malhotra (2018) cited in WHO (2018) Engaging private healthcare providers in TB care and
prevention: a landscape analysis
54
Wyeth/Global Pharmaceuticals Ltd

44
Table 17. Case finding by different types of private provision, 2015-2018. Source: Guy Stallworthy

Description 2015 2016 2017 2018

Notifications
PPM1= GP 26,292 53,040 66,826 72,511
PPM3 = Pte Hosp 10,525 13,063 13,729 13,891
subtotal private for-profit 36,817 66,103 79,332 86,402
PPM2 = NGO 27,461 29,533 33,090 29,608
PPM4 = other public 5,846 2,533 4,017 3,804
Subtotal PPM 70,124 98,169 114,974 119,814
Percent of total notifications
PPM1= GP 8% 15% 18% 20%
PPM3 = Pte Hosp 3% 4% 4% 4%
subtotal private for-profit 11% 19% 22% 23%
PPM2 = NGO 8% 8% 9% 8%
PPM4 = other public 2% 1% 1% 1%
Subtotal PPM 22% 28% 32% 32%
Number of participating facilities
GPs (PPM1) 1,991 3,316 2,891
Labs (PPM1) 425 431
Private hospitals (PPM3) 27 35 45 84
NGO (PPM2) 105 122 158 158
Other public (PPM4) 57 33 30 41

The proportion of pulmonary TB cases that is bacteriologically confirmed is particularly low in PPM:
42% overall, and just 37% for GPs, in 2017. The NTP is not able to disaggregate treatment success
rates for PPM.

Greenstar Social Marketing (GSM) and Mercy Corps (MC) --with its 6 NGO sub-recipients-- implement
very similar models of GP engagement (PPM1) in 20 and 65 districts, respectively. They deploy one
field worker to support an average of 15 GPs. The approach consists of: mapping and selection of
providers; short training for GPs and their paramedical staff; engagement and equipment for private
labs; provision of free NTP drugs for notified TB patients; payment of small incentives for GPs and lab
staff; deployment of NGO field staff who carry much of the reporting and recording burden; and
quarterly review and data validation meetings with the District or Provincial Programme. A published
study demonstrated a 71% increase in case notifications by GPs after the introduction of cash
incentives in 2015.55 GSM and MC report treatment success rates among patients treated by private
providers in excess of 90%, whereas a published study reported 81% treatment success amongst 883
TB patients treated by private providers in Lahore in 2015.56

Since 2015, Community Health Solutions (CHS) has developed a network of 61 Sehatmand Zindagi TB
diagnostic and treatment centres, supported by 20 vans equipped with digital x-ray for mass
screening. In 2018, the centres that had been in operation for the full year detected an average of 22
cases per centre per month. Each centre drew presumptive cases from an average of 58 GPs and

55 Ashraf R et al (2018) Does cash incentive effect TB case notification by Public Private Mix General
Practitioners Model in Pakistan? Journal of Tuberculosis Research 6, 166-174
56
Khan BJ et al (2017) Alarming rates of attrition among tuberculosis patients in public-private facilities in
Lahore, Pakistan, Public Health Action 7(2): 127-133. The study also reported 64% initial loss to follow-up, but
acknowledged that it was not able to account for patients treated at public facilities or at private facilities not
included in the study, so the degree of overestimation is unknown

45
diagnosed cases from an average of 24 GPs. In 2018, 54% of cases were referred from private
providers, 25% came from screening camps, and 21% were walk-ins.

The leading NGO provider of TB services is the Pakistan Anti-TB Association (PATA), which has been
active since 1955, operates 42 centres, and contributed 18,000 cases in 2017.

Private hospitals have made steady contributions of around 15,000 cases per year in recent years,
while the contribution of parastatal facilities has been small. The leading contributors are the Gulab
Devi Hospital in Lahore and Indus Hospital Network (IHN), based in Karachi. IHN is funded by the
Global Fund to use the FAST approach57 to actively detect TB cases in 22 public and private hospitals
and to conduct contact tracing and operations research. IHN has also led the development of MDR
treatment, currently managing 10 of 33 PMDT sites in Pakistan. The NTP has recently begun to
strengthen partnerships with the Agha Khan Development Network (which operates over 450 clinics,
5 secondary hospitals, and the flagship AKUH in Karachi58) and 15 major Military Hospitals. Both
partnerships seem to have the potential to contribute substantially to TB case notification if properly
managed.

IHN, CHS, GSM and MC invest considerable resources in a variety of mass screening camps, sometimes
with digital x-ray and Xpert, at hospitals, outside GP clinics, or in communities and worksites. In 2018,
they conducted 4,667 screening camps of various kinds, and found 5,838 cases. Analysis for the JPRM
in 2019 suggested that these resources could be more effectively deployed to expand passive case
finding in private facilities.

Some provinces have contracted out the management of many of their public healthcare facilities to
NGOs. In Sindh, the People’s Primary Healthcare Initiative (PPHI) manages 971 public primary care
facilities (58% of the total) while Integrated Health Services (IHS) manages 96 Rural Health Centres
(73% of the total).

Most provinces have passed Mandatory Notification Acts, providing for jail terms up to two years for
healthcare providers who fail to notify TB cases. Implementing regulations have not been issued, but
pilot projects have been initiated in 5 districts, 3 in Sindh and 2 in KP. An electronic case notification
system via a call centre has been started and a help line has been introduced.

Strengths, challenges and opportunities

There are several strengths in PPM in Pakistan and opportunities for improving it. The NTP has very
strong NGO partners with many years of experience engaging private providers. There are precedents
for government contracting of NGOs in health, and since 2015 there has been provision for TB strategic
purchasing from private providers. There is considerable innovation within the PPM field in Pakistan.
Mandatory Notification Acts have strengthened the legal foundations of PPM and the NTP is
motivated to explore ways of effectively implementing them. Pakistan has made progress in the
development of a national social health insurance program, targeting low-income families and
contracting private as well as public hospitals. The benefit package does not yet include TB, and
primary care facilities/services are not yet covered, but such schemes have the potential to play a key
role in both the financing of TB care and the engagement of private healthcare providers as they
develop over the medium- and long-term.

To realize the potential for PPM in Pakistan, it will be necessary to overcome several challenges and
constraints. PPM initiatives have not reached a scale that is commensurate with the magnitude of the

57
Find cases Actively, Separate safely and Treat Effectively
58
https://www.akdn.org/where-we-work/south-asia/pakistan/health-pakistan

46
TB epidemic or the role of the private sector, especially at the primary care level. Given its importance
for TB prevention and care in Pakistan, PPM has been relatively neglected in previous National
Strategic Plans and in budget allocations. Funding for PPM remains insufficient and has been almost
entirely dependent on external donors, mainly the Global Fund. PPM partners have been trying to
use the same paper registers and forms as are used in the public sector, rather than benefitting from
modern digital, case-based systems. In some cases, relationships between NGO partners and the
NTP/PTPs have suffered from rivalry, competition and mistrust.

The 2019 JPRM concluded that Pakistan will not achieve the End TB goals and targets unless it
prioritizes a major expansion of PPM, based on a spirit of genuine partnership. It recommended that
the proportion of private primary care providers actively engaged in the TB program should be
increased from <5% to >20%, and that the number of privately-managed TB patients receiving the
full package of publicly-funded TB services should double within three years. Specific
recommendations included increasing private patients’ access to Xpert, making full use of modern
digital technologies, and increasing engagement of private labs, pharmacies and informal providers.
It will not be possible to meet any of Pakistan’s TB goals without systematic and full-scale
engagement of Pakistan’s dominant private sector. Strong foundations for private provider
engagement have been built over the last 15 years, and Pakistan has several NGOs that are world
leaders in this area.

Unqualified providers – drug sellers, hakims, “quacks” - also provide services to people with TB in
Pakistan, but little is known about them. The attitude towards them among the public services is that
they should simply refer any suspected cases to a qualified practitioner. Unless this is linked to some
kind of monetary incentive it is unlikely to succeed. A more useful strategy would be to combine that
with using them as treatment supporter, especially if that role comes with an honorarium of some
sort. Bangladesh’s Damien Foundation has successfully employed them in this way for several years.
In northern India, informal providers are very often linked to qualified providers in nearby towns (for
referral, learning).

2.4.5 TB in children
The problem
Pakistan reported 47,804 children (0-15 years) with TB in 2018 - a 7.7% increase from 2017, and very
close to the UNHLM TB target for children of 48,600 for 201859. Sindh contributed 45% of this
increase and reported 13,352 children with TB in 2018 (up 13% from 2017). Punjab with 60% of
Pakistan’s population is expected to contribute the bulk of TB notification, however it contributed to
7% of child TB in 2018.

The drivers of TB in children in Pakistan include the high levels of chronic and acute malnutrition that
still exist, with over 10 million stunted children60. Malnourished children with TB are at risk of high
mortality rates. HIV is a further driver, and TB is the biggest killer of children living with HIV (CLHIV),
in TB endemic settings61. An HIV outbreak occurred in the district of Larkana in Sindh in April 2019,
as a result of unsafe injection practices. More than 600 children with HIV have been identified, more

59
UNHLM TB country commitments 2018. Available from:
http://www.stoptb.org/assets/documents/global/advocacy/unhlm/1.%20UNHLM%20on%20TB%20-
%20TB%20Country%20Targets.pdf
60
UNICEF. Nutrition in Pakistan. 2018.
61
WHO. Global tuberculosis report 2018. Geneva, Switzerland: World Health Organization; 2018.
WHO/CDS/TB/2018.20. Available from: http://apps. who. int/iris/bitstream …; 2018.

47
than half of whom are <5 years age. The biggest challenge in tackling the outbreak and the
increasing numbers of children found with HIV has been lack of safe and effective systems,
diagnostic capacity and ART for children in Sindh.

The recent achievements in childhood TB have brought Pakistan closer to the target expected by the
global community than in any other indicator. However, evidence of clear over-diagnosis of extra-
pulmonary TB, particularly abdominal TB from some sites in the regions, and marked under-
detection in Punjab (a detection gap of >50%) and significant underreporting from the private sector
(78% not reported)62 need urgent attention. A recent inventory study in childhood TB has
emphasized the amounts of TB diagnosis in the private sector, largely based on X-ray, and the
massive under-reporting63.

The solutions
Still needed in Pakistan are approaches that build on the WHO Roadmap towards ending TB in
children and adolescents and with the aim of reaching the UNHLM TB targets and that include the
following approaches:

1. Strengthened advocacy at all levels- needs to locate child TB firmly in national and
provincial health agendas and the Prime Minister’s malnutrition reduction drive in order to
garner the urgent investments required to meet the UNHLM targets. Accountability
mechanisms should be included.
2. Partnerships between public and private sectors to work on a united front to end TB.
1. Dedicated funding for child TB training and implementation within the hybrid NGO-
private, NGO-public TB care models that have shown success for adult TB;
2. Implementation of routine reporting of children with TB to the NTP;
3. Engagement and support of the private sector, as well as the community and PHC
models to provide TB preventive therapy (TPT);
4. Continued engagement of the Pakistan Paediatrics Association and private provider
training in child and adolescent TB, TBHIV, DRTB.
3. Scale-up of TB case finding including the adaptation of the child TB models that have
worked in the Karachi zero TB initiative to other parts of Pakistan, namely screening at
hospitals and clinics, training of frontline providers, and easy access to current quality
diagnostics and child friendly FDCs and TPT ,as well as screening camps/vans that include
children.
4. Integrated services for TB/HIV/malnutrition with testing, treatment and follow-up in
specific sentinel facilities. As HIV services are implemented and expanded to meet the
crisis, TB symptom screening will be carried out at each CLHIV visit (to promptly diagnose
and treat active TB, or LTBI).
5. Implementation of mechanisms to enhance diagnostic accuracy in the potentially over-
diagnosing districts (through clinical audits, training, clinical oversight)

62
Fatima R, Haq MU, Yaqoob A, Mahmood N, Ahmad KL, Osberg M, et al. Delivering patient-centered care in a
fragile state: using patient-pathway analysis to understand tuberculosis-related care seeking in Pakistan. The
Journal of infectious diseases. 2017;216(suppl_7):S733-S9.
63
Fatima R, Yaqoob A, Qadeer E, Hinderaker SG, Ikram A, Sismanidis C (2019) Measuring and addressing the
childhood tuberculosis reporting gaps in Pakistan: The first ever national inventory study among children. PLoS
ONE 14(12): e0227186. https://doi.org/10.1371/journal.pone.0227186

48
2.4.6 TB/HIV and other comorbidities
The problems
Around 165,000 people are estimated to be carrying HIV in Pakistan, of whom only 26,000 are
registered and 18,600 are on ART. The HIV epidemic is therefore concentrated at less than 0.1% of
the population, and is localised, but it is rising steadily. Of the at-risk populations IDUs make up 38%
of the infected, transgender 7.2%, MSM 5.6%, and FSW 2.2%. Among the people using drugs
(PUDs), the highest concentrations in 2017 were found in Kasur (51%), Karachi (49%), and
Bahawalpur (26%), while they are below 10% in Quetta, Bannu and Peshawar. Each year there are
thought to be over 20,000 new infections, predominantly among clients of FSW, and men who have
sex with men (MSM)64. These are the fastest growing groups of those with HIV.

Meanwhile, outdated and hazardous injection practices have been shown to fuel outbreaks of HIV
such as the one in Larkana district, Sindh, where 1,150 people were found to be infected with HIV, of
whom 890 were children. Among these, 13 cases of TB were identified at the same time as the
discovery of HIV.

The central TB/HIV Coordinating Committee meets only annually. There are serious gaps in the
coordination of TB and HIV activities in Punjab, while it is considered better in Sindh and KP. The
NACP collects case-based HIV data, while the NTP does not. HIV testing of patients with TB is well
below WHO recommendations, at x% nationally in 2018. Only 636 HIV infections, out of the
7,000 estimated HIV-infected TB patients were identified in TB patients in 2018, at a rate of <1%.
Conservative attitudes of clinicians restrict the number of those to whom ART or preventive therapy
or treatment of LTBI/PET is offered. Other, shorter, preventive regimens are not prescribed. TB
screening of PLHIV by the four-symptom screen should happen at all visits to OPD, but the level of
adherence to this policy is uncertain.
There are no records as yet of MDR-TB outbreaks among PLHIV, indeed, MDR-TB has yet to be
detected in PLHIV in Pakistan.

There is an urgent need to enhance the implementation of TB/HIV collaborative activities in

Pakistan.

Diabetes mellitus
With the large burden of diabetes in Pakistan (11.7 - 17% prevalence in adults, see 2.3.2), it is highly
likely that a significant proportion of the TB disease burden is driven by this condition. Diabetes has
risen to 10th in the list of diseases causing most deaths in Pakistan in 2017. However, the proportion
of cases of diabetes that currently has TB in Pakistan, or will develop it over the course of a year is
unknown.
While a significant number of TB patients will also have diabetes, and WHO recommends that all
patients be so tested, random blood glucose estimations are not always performed, and there are no
summary data on this within the NTP.
Emphasis therefore needs to be increased, first, on the detection of diabetes among TB patients,
since ensuring proper control of blood glucose during the course of TB treatment has been shown to
significantly improve TB outcomes. Secondly, operational research should be carried out to
ascertain the prevalence of TB among diabetics that are reachable, in reasonable numbers, within
the health system, public or private. Studies in other countries give very variable figures for TB
among diabetic cases, and it is not worth routinely testing until such research has indicated the scale
of the problem.

64
Asian Epidemic Model.

49
2.4.7 Research/Innovation
Research is a key strategic area and core component identified in Pakistan’s National Strategic Plan
and operational (PC1) plans, as well as in Pillar III of the new WHO END TB strategy. In 2009, a research
unit at the NTP was set up with the aim of designing and conducting locally relevant operational
research.
The research unit has been conducting international Structured Operational Research and Training
Initiative (SORT IT) courses in Pakistan under the joint collaboration of WHO TDR and the Global Fund
since 2016. Through this initiative, 45 research papers have been published in international peer
reviewed journals, and the unit has been recognised as an exemplar in national operational research65.
Participants on the training courses have come from national and provincial TB, malaria and HIV/AIDs
programmes, the National Institute of Health, Pakistan Health Research Council, Médecins Sans
Frontières (MSF), the Health Services Academy, and research institutions. TB topics studied range
from TB diagnostics, active case finding, TB in prisons, public private mix, to MDR and comorbidities
associated with TB. Studies on HIV, malaria, maternal and child health, hepatitis, and measles have
also been undertaken.
The research unit has designed and implemented several research projects and national level surveys
on priority programme needs. These include the National TB Prevalence Survey, 2010-1166 and two
national inventory studies to measure the under-reporting of TB cases among adults67 and children.
Studies on intensified case finding using chest camps to find cases in slums68, engaging private
providers, and examining the effectiveness of widening the circle of contact screening using GIS69 have
been performed. A trial to assess the effectiveness and feasibility of 2 months hospitalization vs 1
week hospitalization for MDR-TB in Pakistan has been completed. Recently, the unit has conducted a
multi-country, double-blind placebo controlled trial on tobacco cessation. Subsequently,
incorporation of smoking cessation questions in the recording and reporting tools have been piloted
in KP with the aim of scaling up across the country.

The Union’s TB and Diabetes Guidelines70 were piloted in Pakistan in collaboration with the UNION.
The CMU Institutional Review Board was established in 2018 to provide reviews of research
proposals to local researchers, free of cost.

The unit aims to play a leading role in the upcoming patient cost survey, and the repeat TB prevalence
survey with sub-national level estimates, for which it will require significant resources. With the UK

65Fatima R, Yaqoob A, Qadeer E, Hinderaker SG, Heldal E, Zachariah R, Harries AD, Kumar AM. Building sustainable operational research
capacity in Pakistan: starting with tuberculosis and expanding to other public health problems. Global health action. 2019 Jan
1;12(1):1555215.
66
Qadeer E, Fatima R, Yaqoob A, Tahseen S, Haq MU, Ghafoor A, Asif M, Straetemans M, Tiemersma EW.
Population based national tuberculosis prevalence survey among adults (> 15 years) in Pakistan, 2010–2011.
PloS one. 2016 Feb 10;11(2):e0148293.
67
Fatima R, Harris RJ, Enarson DA, Hinderaker SG, Qadeer E, Ali K, Bassilli A. Estimating tuberculosis burden
and case detection in Pakistan. The International Journal of Tuberculosis and Lung Disease. 2014 Jan
1;18(1):55-60.
68
Fatima R, Qadeer E, Enarson DA, Creswell J, Stevens R, etal. Success of active tuberculosis case detection
among high-risk groups in urban slums in Pakistan. The International Journal of Tuberculosis and Lung Disease.
2014 Sep 1;18(9):1099-104.
69
Fatima R, Qadeer E, Yaqoob A, ul Haq M, Majumdar SS, Shewade HD, Stevens R, Creswell J, Mahmood N,
Kumar AM. Extending ‘Contact Tracing’into the Community within a 50-Metre Radius of an Index Tuberculosis
Patient Using Xpert MTB/RIF in Urban, Pakistan: Did It Increase Case Detection?. PloS one. 2016 Nov
29;11(11):e0165813. Accessed 15th December 2019.
70
The Union. Management of diabetes mellitus-tuberculosis: a guide to the essential practice
https://www.theunion.org/what-we-do/publications/technical/management-of-diabetes-mellitus-
tuberculosis-a-guide-to-the-essential-practice

50
Department for International Development (DFID) withdrawing from the SORT-IT consortium, the
sustainability of SORT-IT courses beyond 2020 is a challenge.

51
3. Gap analysis
The main gaps in TB control in Pakistan are in political commitment, case finding in both adults and
children, the transport of sputum to enable a bacteriological diagnosis, the prevention and
management of drug resistance, monitoring and evaluation, and last, but not least, organisation and
management.

The JPRM put its finger on a massive gap in Pakistan’s political commitment to TB control in the
2019 review. Policy makers at the highest level were unaware of the burden of TB in the country.

This lack of awareness is translated into a lack of financial support for TB control. Federal level
funding for TB control is virtually zero, and provincial support is mostly limited to infrastructure and
staff costs within the regular budget, while only some US$ 11 million annually are made available to
TB control activities. This latter amounts to about US 5 cents per person per year for a disease killing
43,000 citizens each year.

Lack of awareness of TB also prejudices the political and administrative connections required to
build up the coalition of forces within the health system, both public and private sectors, as well as
outside the health system, that is required for a multi-sectoral approach to TB control. The
MOHNSRC, and provincial health ministries are almost entirely on their own, when addressing the
issue of TB in prisons, or the military, or other parastatal health organisations – or they avoid doing
so. TB is found most often among the poor, and is itself a potent cause of poverty, yet it is not
addressed by Pakistan’s social protection mechanisms, SSP, PBM and BISP. The President’s TB Free
Initiative has fizzled out before it really began. Multi-sectorality in TB does not therefore yet exist.

After some impressive increases in case notifications up until 2017, case finding has flat-lined in
2018 and begun to fall in the first quarters of 2019. The JPRM was instrumental in bringing this to
attention, and analysing the causes – the majority of facilities within the public health delivery
system is not engaged in TB control activities. Nor is most of the private health sector – only 4% of
GPs are collaborating with PTPs, even though the private PRs, Mercy Corps and the Indus Health
Network, have shown how to involve different facilities within the private sector, especially the GPs.

Therefore, in neither sector are patients with the disease referred in a timely fashion for further
investigation. In Sindh in 2018, PPHI had identified 250,000 suspect cases, but could only investigate
38,000. The BHUs of the remaining patients had no mechanisms for referring patients for further
investigation. This was compounded by frontline physicians being untrained, and the chief point of
access to health care in the community, the LHWs, being uninvolved in TB case finding or case
holding. Although most patient go first to the private sector to seek health care, especially to the
pharmacies, there are no means at that level to suspect or detect TB.

The contacts of cases, especially (but not only) those of bacteriologically positive cases, are not
routinely being identified for the reasons given in 2.4.1, and the results of the UNHLM mean that
now, for the first time, there needs to be an effort to provide preventive therapy to contacts over
the age of 5 years. This plan will address this age group for the first time in Pakistan’s history.

In addition, the currently used diagnostic algorithm, especially in the public sector, still largely relies
on symptom screening and sputum smear microscopy and is therefore too insensitive. New
molecular technologies, such as GeneXpert, are significantly more sensitive, and exist in significant
numbers in Pakistan, but are not sufficiently used for detecting cases of TB (as opposed to
identifying cases of drug resistance).

52
However, to use the GeneXpert machines efficiently there needs to be a systematic, regular, reliable,
and effective transport system to take sputum from the BMUs to the nearest GeneXpert facility.
This is a major issue that has not yet been solved by any province or region. Simply relying on health
workers who may be travelling in that direction is not effective. Nor is relying on local “riders”. This
Plan will address a systematic, coordinated approach to specimen transportation that recognises
that what is required is a major, province-wide, logistics operation that needs to be carried out by a
transport company or courier with a network of vehicles, motorbikes and drivers, and extensive
experience of this kind of work. Even more important, given the intention to engage BHUs much
more, is the issue of specimen transport from the BHUs to the nearest BMU.

Finding the TB that we know is in children is another gap. While Sindh has shown the way forward
and reported 13,352 children with TB in 2018 (up 13% from 2017), no other province or region has
shown the same determination. The Punjab has 60% of Pakistan’s population but contributed <30%
of child TB in 2018.

The chief issue in drug resistance presently is the flat case detection. Also, the limited number of
PMDT treatment sites, located miles from patients’ communities, is putting patients off from
coming. Treatment success is also still too low, and the new, more effective, all oral regimens
recommended by WHO that include the new drugs, bedaquiline and pretomanid, are yet to be
introduced widely.

Viewed together, these missed opportunities for case finding constitute a crisis that this plan will
address head on.

Better monitoring and evaluation guidance from the NTP’s central M&E unit is urgently needed, in
the form of simply written standard operating procedures, to guide all frontline staff in the use of all
the TB forms and registers. Crucial information especially on TB/HIV, contact screening and
preventive therapy provision is not currently collected. Many M&E functions would be made much
more efficient by a case-based data system for TB notification, provider engagement and patient
tracking, with 100% coverage of all TB notifications, which is currently lacking. Punjab is developing
its own approach, but there is a risk that Pakistan will not have a standardised approach to national
monitoring unless leadership is displayed at the national level.
Leadership from the central level in Pakistan is hindered not only by a lack of Federal resources, but
also by an organisational structure and management that seriously inhibits it. Employed as they are
by the Global Fund, the staff of the CMU are bound to prioritise the work of the Global Fund rather
than respond to national priorities. For example, resources will tend to flow towards monitoring of
Global Fund indicators and funding flows rather than the development of clear guidelines and SOPs
for monitoring the epidemic in-country, or ensuring that all components of the case-finding pathway
are functioning well, eg the presumptive registers. There are gaps in policy development, guideline
dissemination and SOPs, not only in M&E, but also in TB/HIV, PMDT (including the new drugs), and in
challenging (relatively) new issues, such as management of latent infection, how to address the
diabetes epidemic, etc.. The (highly competent) current staff are insufficient in number to address
these needs.
Collaboration with other health programmes also needs much more work, quite apart from
Ministries, NGOs, community based organisations, and corporations outside the health sector. It
should perhaps be added that the failure of the public sector and private sector to even
communicate on such a vital health issue as TB in the preparation of this NSP is a very great pity.
The people of Pakistan will suffer as a result.

53
4. Vision, mission and goals
Vision of the NSP 2020-2023
TB-free Pakistan with zero deaths, disease, and poverty caused by TB

Mission
To effectively end the TB epidemic in Pakistan by 2035

Goal, impact and targets

To get on track to end the TB epidemic by 2030

If achieved, this goal will establish Pakistan on the road towards achieving universal access to TB
diagnosis and treatment by 2030.

Targets for the goal: 1.9 million people successfully treated and 1.6 million started on preventive
treatment in the 4 years, 2020 – 2023.

Table 18. Treatment targets for drug sensitive (DS) patients, children, drug resistant (DR) cases,
and preventive treatment, and total costs of the PSPs, 2020-2023.

Province/region/ DS adults DS children DR patients Preventive Total cost

territory treated treated treated treatments US$ million
AJK 31,463 3,526 753 55,605 15.383
BAL 53,963 7,709 1,242 56,726 28.553
FATA 26,390 2,456 485 34,137 14.325
GB 11,991 1,091 202 14,409 9.605
ICT 14,239 1,708 299 16,550 5.754
KP 238,793 29,849 4,518 162,206 48.945
PJB 951,521 85,446 18,826 931,638 387.899
SND 385,456 77,091 7,306 562,462 100.588
Federal Unit - - - - 14.767
Total 1,713,816 208,876 33,631 1,729,582 625.819
DS adults and children
combined 1,922,692

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Summary plans of Provinces, Regions and Territories
Khyber Pakhtunkhwa – Total plan cost US$48.945 million
Objectives Strategic Areas Main components (not comprehensive) Cost (US$ million) Targets
1. Increase case detection 21.352 Adults: 238,793
from 52% to 68% and TB Free Cities ACF (including mobile Xray vans) 5.9 Children: 29,849
maintain treatment Childhood TB Diagnosis and Rx 1.7
success rate at >90% Preventive therapy 0.8 Preventive
Strengthening case Hospital DOTS linkage therapy: 2,868
detection Digital XRay machines
TB/DM
TB in prisons Screening
Expansion of PPM-1 2.2
Contact management 0.8
Primary health care LHWs 0.1
BHUs 0
Sputum transport mechanism 0.1
Drugs 6.0
Laboratory 1.6
strengthening
2. Increase case detection 15.6 4,518
of drug resistant TB Satellite sites (13) 9.9
from 354 to 4,518 58 Xpert sites 5.3
(cumulative) with a
treatment success rate
of 65-75%
3. Strengthen Monitoring 1.5
and Evaluation
4. Research Partnerships 0.44

55
Balochistan – total cost US$28.553 million
Objectives Strategic Areas Main interventions (not comprehensive) Cost (US$ million) Targets
1. To increase notified DS TB 16.992
cases 31% in 2018 to 50% by Increase sensitivity of Procure Xpert machines 6.96 Treatment DS-TB:
2023 with increasing and diagnosis Expand LED microscope 1.1 53,963 adults,
maintaining TSR from 88% Install dXRs at THQ level 4.9 7,709 children
to above 90% Expand case finding by BHU strengthening 0.06
strengthening services PPM 0.09
Household contacts 0.1
HDL extension 0.4
ACF (prisons, IDPs, refugees, madrassas) 1.5
Childhood TB 0.05
Drugs 1.6
2.Increase enrolment of DR- Shorter regimens 3.334 1,242
TB (30%-90%) and increase Increase PMDT sites
treatment success rate Increase support
(pharmacological,
psych., social)
3.Increase Preventive Increase screening of 0.211 Preventive Rx:
therapy HHC and others 56,726

4.Strengthen programme Restructure surveillance 3.725

management capacity of Increase M&E support
PTP
5.Operational research Research cell 0.16
establishment
Research activities

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Sindh total cost US$100.588 million
Objectives Strategic Areas Main interventions (not Cost by objective Targets
comprehensive) (US$ million)
1. Enhance treatment Enhance case detection in the public sector -Establish 150 additional BMUs See budget files DS adults
coverage in Sindh province -Strengthening Hospital DOTS treated:
from 59% in 2018 to more Linkages (HDL) 385,456
than 80% by the end of -Enhance role of LHWs Children:
2023. -Capacity building of health staff 77,091
-Inclusion of CAD4 X-Ray machines
in diagnostic algorithm
Scaling up of PPM-1 -Childhood TB
Engage pharmacies in 03 districts -Engage GPs
Enhance case finding in diabetics and HIV risk
groups
TB/HIV collaborative activities
Increase ACF 562,462
Enhance contact management preventive
Increase B +ve proportion treatments
ACSM
Scale up mandatory notification
2. Multi-sectoral Provincial Steering Committee chaired by Chief
involvement Minister Sindh
District level task forces
Increase patient support
3.Enhance M&E, Case-based DHIS2 electronic registers
surveillance and supervision Quarterly surveillance meetings
Increase district level M&E and supervision
4.Increase detection of RR Scale up culture capacity 7,306
TB in Sindh from 75% among To decentralize DR TB care to district level
notified TB cases in 2018 to Scale up LPA (from 3 to 8)
90% by 2023 Active screening DR contacts
5. To reduce primary default Retrieve lost to follow up
from 15% to 0% Ensure all start on treatment

57
6. Decentralize DR TB care Improve access to DRTB care services through
to district level establishing five more PMDT sites
Capacity building of docs and others on DR-TB
Redistribution of PMDT sites

58
Punjab Total plan cost US$ 387.899 million
Objectives Strategic Areas Main interventions (not comprehensive) Cost by objective Targets
(US$ million)
1. a. Increase Case Detection 1. Engagement of Sputum transport (community riders DS adults treated: 951,521
Rate of DS-TB from 75% in BHUs managed by PPM partners, plus hiring
2018 to 80% by 2023 Tehsil level assistants)
Engage LHWs
Loosen diagnostic criteria
b. Increase Case Detection 2. Increase in CAD4TB digital XR machine procurement Children : 85,446
Rate of Childhood TB Presumptive Hospital/ DOTS Linkage
from 7% in 2018 to 13% identification and Inclusion of GeneXpert in diagnosis of TB
by 2023 testing Childhood TB training for BMU staff
Contact screening by PPM field force and
Tehsil TBAs
3. Contact screening Mandatory notification Act dissemination
PPM-1 remodelling
4. Enhance role of Ban OTC sale of anti TB Drugs
private sector Engage pharmacies
Inclusion unqualified practitioners
Camps – conventional and plus X-rays
Prison screening, elderly, mental
5. Active Case Finding patients, rehabilitation centres, PWUD,
orphanages, transgender, hospital staff

6. Intrasectoral Stigma reduction, SMS, community

coordination information
7. TB awareness and
education
8. Monitoring and Designated DTOs
supervision Case based electronic recording &
reporting + android application

59
 9. Laboratory Additional Xpert machines, LPAs,
enhancement expansion culture + DST
10. Multisector task
forces
11. Hospital DOTS links
12. Prevalence Survey
13. SORT-IT courses

2. Increase CDR DR-TB from 1.Enhanced Testing for Increase Xpert testing of presumptives 18,826
30% in 2018 to 80% by 2023 DR-TB GxAlert; sputum transport; web portal to
among notified BC link PMDT sites; increase social support
Pulmonary TB Cases.
3. Maintain treatment 1.Ensure completion Counselling
success rate of DS- TB above Defaulter tracing
90% Patient support for DS patients
Reminder SMSs generated as in 1.8
2.Un-interrupted supply
of QA drugs
4.Maintain Treatment 1.Ensure all registered Counselling
Success Rate of DR-TB above DR-TB patients to Default tracing
90% by 2023 from 65% in complete their Increased social support
2018 treatment Decentralisation of PMDT sites
aDSM and pharmacovigilance
2. Ensure un-interrupted
supply of QA SLDs

5. LTBI treatment in at least 1.Enhanced Contact As in 1.3 931,638

40% contacts of BC TB cases Screening
by 2023 2.Implementation of New guidelines; training of trainers, PPD
LTBI Management procurement

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AJK - Total plan cost US$15.383 million
Objectives Strategic Areas Main interventions Cost by objective Targets
(not comprehensive) (US$ million) 8.894
1.To Increase number of TB -Increase the number of BMUs, 12 to 227 Training and DS adults to be treated:
cases notified annually, -Increase childhood TB notification from procurement 31,463
from 5,146 in 2018 to 9,210 386 (7.5%) in 2018 to 1197 (13%) in 2023
by 2023 while maintaining -Referral linkages between public sector Children: 3,526
TSR above 90% BHUs and BMUs
-Specimen transportation system from
BMUs to nearest Xpert site
-Expand Xpert testing sites from 11 to 17
-Expansion of PPM-1 involving 80 GPs and
16 pvt labs
-ACF by camps with 3 CAD4TB vans
-Increase community awareness
-Mandatory TB notification
-Managing TB patients with other
comorbidities
2. increase enrollment of DR -Universal Xpert testing for sputum smear Treatments: 753
TB from 25 in 2018 to 265 in positive TB patients
2023 -Decentralized DR TB services 8 districts
-Increase PMDT sites from 1 to 2
3.Preventive TB services all -100% Household contact screening of BC TB 55,605
districts of AJK patients

4.Establish and implement 1.Prevention of infection in HCP

Infection Prevention & 2.Infra-structure modification
Control (IPC) in all BMUs

5. Establishment of Regional 1. Strengthening HR of RTP

TB Control Program and 2. Office equipment & Furniture
improve M&E 3.Improved M&E methodologies and
methodologies surveillance

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FATA – totalcost US$ 14.325 million
Objectives Strategic Areas Main interventions (not Cost by objective Targets
comprehensive) (US$ million)
1.Increase the number of Expand the TB care services from 27 to 60 PHC & 19 Adult
notified DS TB cases from secondary level hospitals by 2023 treatments:
4,539 cases in 2018 to 7,829 Improve presumptive referral from the community by 26,399
cases by 2023 while involving 1000 LHWs, 02 NGOs/ district and 50
maintaining the treatment community volunteers/ district
success rate above 90% Active case finding through mobile outreach, chest
camps (80 activities/year) 320 activities till 2023.
HH Contact Screening of 100% of B+ registered TB
patients
Ensure un-interrupted supplies of FLDs for DS TB
patients by strengthening drug management All B+
registered patient's household contact tracing will be
done by 2023 Children
Expand childhood TB case management from current treated:
07 Agency Head Quarter hospitals to all 27public 2,456
sector BMU
Improve coverage of new diagnostic services by scaling
up of Xpert from 06 to 14 and Installation of 55 Digital
X-Rays at BMUs level.

2.To establish PPM-1 in 10 Scaling up of PPM-1 model to 10 districts by addition

districts through 50 GPs, of 08 private labs & 50 GPs
PPM-4 in 8 Private Hospitals Expansion of PPM-4 model by involving 08 private
to register 500 cases per hospitals
year Monitoring & Supervision of PPM Intervention

62
3.Increase DR TB Establishment of 02 PMDT sites 485
notification from 43% (37 Establishment of 02 BSL-II labs
cases) in 2018 to 80% (165 Establish sample transport mechanism from non x-pert
cases) by 2023 while BMUs to X-pert/ PMDT sites
increasing treatment
success rate from 57% in
2018 to 90% by 2023.

4.Managing high risk groups Screening of all diagnosed TB cases for HIV by the end
and co-morbidities of 2023
Addressing issue of tobacco smoking
Cross border TB case management

5.To provide TB preventive 34,137

therapy from 106 contacts in
2018 to 34,137 eligible
contacts by 2023 Support in surveillance meetings and mobility
6.To increase the
Increasing the contribution of public sector TB
programmatic capabilities
control program funding at least 3 times by 2023
and Monitoring &
Supervision to all BMUs to onwards in comparison to 2018.
strengthen the quality of Hiring of M&E staff for enhanced M&E
Laboratory Network and
Data Validation

63
GB – total cost US$ 9.605 million
Objectives Strategic Areas Main interventions (not Cost by objective Targets
comprehensive) (US$ million)
1.To increase the number of -Mandatory TB Case notification by Presentation of the bill to DS adults treated:
notified TB cases (all forms)the provincial govt by 2020 provincial assembly 11,991
from 2,823 in 2018 to 3,207 -Expansion of TB diagnostic facilities
by 2023 by addition of 17 BMUs by 2023 Children:
-HDL CMH Gilgit and Skardu 1,091
- Develop sputum transport
mechanism from peripheral HF to
Xpert sites
- Involvement of LHWs and CMWs
-Community empowerment by Preventive treatments:
community mobilization activities 14,409
- Strengthening of DHIS-2 for quality
data collection
2. Improve bacteriologically - Enhancing the skills of Lab
confirmation among notified Technicians
cases from 344 (16%) to -Training of paediatricians, general
2405 (75%) by 2023 physicians and paramedics on
childhood TB guidelines
- Capacity building for health staff on
new diagnostic algorithms
3. To increase DR-TB Cases -Scaling up of DR TB diagnosis by DR cases to be treated: 171
from 3 in 2018 to 83 cases involving 08 new BMUs, two CMHs
by 2023 and City Hospital Gilgit
- Establishment of sputum sample
transport mechanism from PMDT site
to culture lab
- Decentralized DR TB services in 9
districts and enhanced HH contact
screening of DR TB pts

64
 - Improved infection control at 44
BMUs
4. To increase PPM Engaging private sector in TB case
contribution from 803 cases management including new four
in 2018 to 962 cases by districts
2023 in all type of TB case
notification.
5. To enhance technical & -Enhancing HR for PTP
M&E capacity of the -Improved M&E
Provincial Program

ICT – total cost US$5.754

Objectives Strategic Areas Main interventions (not Cost by objective Targets
comprehensive) (US$ million)
1.To increase the number of Scale up of public sector BMUs by engaging 34 DS adult cases
notified TB cases from 34% new BHUs, CDA medical centers, MCH center, treated: 14,239
(1,820) in 2018 to 80% federal government dispensaries andparastatal
(4,569) by 2023 while hospitals to provide TB care services
increasing the treatment Hospital DOTS linkages in all of the 6 tertiary care
success rate from 66 to 90% hospitals
Mandatory TB Case notification by 2020
Effective sputum transportation mechanism to
Xpert site through courier service
Scale up childhood TB Child cases
Contact tracing of DS TB cases treated: 1,708
Infection control in all 50 health facilities
Managing TB with other Co morbidities

65
2. To enhance DR-TB Referral linkages from Xpert site to PMDT site 299
enrolment from 37 cases in Contact tracing of DR TB cases
2018 to 114 case by 2023

3.To enhance PPM Engagement of 100 additional GPs under PPM 1

contribution from 16% (291) model
in 2018 to 32% (1462) by Enhanced case finding by engaging 10 large
2023 private hospitals

4.To provide TB preventive Enhance screening of close contacts through 16,550

treatment to 16,550 eligible dedicated field staff/ LHWs
persons from 2020-2023

5.To ensure and implement Develop a mobile application linked with IDMs
a robust and effective where real time data entry can be ensured of
monitoring and evaluation validated data
system including use of Supportive supervision visits by NTP, NPO, and
digital technology Regional Program

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5. Summary of provincial, regional and territorial objectives
5.1 Political commitment
The NSP aims to achieve the ambitious END TB and UNGA Targets. The NTP and PTPs have
committed themselves, through declaring clearly in this NSP what the country needs to do, to try
and achieve these aims. The Plan will be used to secure and sustain political commitment and to
lead to national ownership of the huge TB problem. It aims to increase financing for TB, especially
sustainable domestic resources, and provide a supportive legal and regulatory environment.
Moreover, the Plan provides a mechanism for oversight for all the anti-TB activities in the Plan, and
will be essential in holding people and institutions to account for performance.

Sindh has committed to move towards a multi-sectoral approach with an accountability framework.
All provinces and regions have shown determination to expand TB service provision (diagnosis and
treatment) into the public primary health care system, as well as enhance and expand private
provider engagement, particularly among GPs, and urgently improve the case finding and treatment
of MDR-TB cases.

5.2 Increasing case finding (DS-TB)

The strong emphasis in all the provincial/regional plans on increasing case finding involves several
different approaches. All provinces and regions aim to significantly increase expenditure on
engaging the GPs as part of the PPM-1 process, including the hiring of PPM coordinators (as in KP)
and field supervisors, including training of all the staff involved. The PHC network (dispensaries,
BHUs, MNCH centres) and, in some provinces, eg Punjab, Sindh, KP, and FATA, the LHWs as well, will
be engaged much more than at present in case-finding and in the process of identification, screening
and assessment of household contacts as well as in the provision of IPT to eligible contacts. In line
with the End TB strategy, and following the successes in this area by Mercy Corps and IHN, all
provinces aim to increase their efforts on active case finding, including new sets of institutions for
investigation eg, madrassas. This work will provide useful information on the TB prevalence in such
places, and whether it is cost-effective to continue such work.
Sputum transportation mechanisms are included in most plans, both for drug sensitive and drug
resistant TB patients, as in Punjab. For the moment they tend to rely on local “riders” and health
staff, rather than the systematic, professional approaches that will be needed if this is to succeed.
Most provinces and regions support expanding the availability of diagnostic services and increasing
the sensitivity of the current diagnostic algorithm through purchase of digital CXR machines for
health facilities with high OPD patient volumes, as well as for ACF. This will require revision of the
current national diagnostic algorithm.

If we say that we anticipate the diagnosis of 1.723 million adult cases of TB, 80% or 1.378 million of
these will be pulmonary. If we assume that 50% of these come from areas where access to X-Rays is
feasible and relatively easy (all urban populations, plus a further 10% of the total), and that each
pulmonary case requires 10 symptomatics in order to detect a case (data from Dr Hadi), then 6.51
million X-rays will be required over a 4 year period, or 1.63 million annually on average. A digital X-
ray machine can perform 150 chest examinations per day, but 70 is more likely, given other
demands on the machine and its operators. At 250 working days per year, one machine can
therefore handle 17,500 examinations annually. This makes a requirement of 93 machines. Allowing
a conservative 10% for imperfect utilisation and distribution, this comes to 102 machines.

Alternatively, for at least part of the need for X-rays, vouchers could be provided for patients to
obtain an X-ray from a private facility. This will have a different set of budget requirements.

67
5.3 Management of drug resistant TB (PMDT)
All provinces and regions will expand availability of PMDT and find more cases. They will further
decentralize management of DRTB from PMDT sites to the district level, under close supervision. As
part of overall efforts to overhaul the sputum transport system, the provinces and regions will
strengthen regular sample transportation from microscopy centers to Xpert sites to ensure full
coverage of drug susceptibility testing/universal testing of rifampicin susceptibility in previously
treated TB cases (currently at 78% of previously treated bacteriologically confirmed (BC) cases, and
44% of new BC cases) , and a rapidly increasing proportion of new TB cases, in line with the NTP
algorithm.
Some provinces will explore expansion of the transmission system of Xpert results (Gx-Alert
currently connects 311 of the 345 Xpert sites – see M&E Plan) to ensure regular flow of Xpert results
from Xpert laboratories to PMDT sites so that all RR patients are started on treatment promptly.
Sindh, for example, will improve access to PMDT services through
establishment of PMDT sites managed by the public sector – with the support of partners. Current
PMDT sites managed by partners will continue as an alternate model.
The Plan aims to increase the number of PMDT sites, as well as organise their decentralisation so as
to make the services they offer more palatable and convenient to patients – and hence more likely
to be used by them. The effectiveness of treatment will be improved by all oral regimens that
include the new, more effective, drugs such as pretomanid, as well as bedaquiline.

5.4 Childhood TB
This NSP plan has borrowed heavily from the WHO Roadmap towards ending TB in children and
adolescents and with the aim of reaching the UNHLM TB targets, and includes the following
approaches:

Strengthened advocacy at all levels- child TB will be firmly located in national and provincial health
agendas and the Prime Minister’s malnutrition reduction drive in order to garner the urgent
investments required to meet the UNHLM targets. Accountability mechanisms will be included.

In this NSP partnerships between public and private sectors will work on a united front that will
include:

1. Dedicated funding for child TB training and implementation within the hybrid NGO-private,
NGO-public TB care models that have shown success for adult TB (Sindh);
2. Implementation of routine reporting of children with TB to the NTP (all provinces, regions and
territories);
3. Continued engagement of the Pakistan Paediatrics Association and private provider training in
child and adolescent TB, TBHIV, DRTB.

Scale-up of TB case finding including the adaptation of the child TB models that have worked in the
Karachi Zero TB initiative to other parts of Pakistan (such as KP), namely screening at hospitals and
clinics, training of frontline providers, and easy access to current quality diagnostics and child
friendly FDCs and TPT, as well as screening camps and vans that include children.

Integrated services for TB/HIV/malnutrition with testing, treatment and follow-up in specific
sentinel facilities. As HIV services are implemented and expanded to meet the crisis TB symptom
screening will be carried out at each CLHIV visit (to promptly diagnose and treat active TB, or LTBI).

Implementation of mechanisms to enhance diagnostic accuracy in the potentially over-diagnosing

districts (through clinical audits, training, clinical oversight)

68
5.5 Support to the laboratory network
This plan will ensure an effective and robust specimen transport system for transport of specimens
from most peripheral health facilities (or communities) to the nearest health facility with Xpert
testing facilities. To further accelerate case finding, this plan will carefully and selectively scale up
Xpert to the sub-district level in a few well-chosen sites, and even to sub-tehsil levels, especially in
the Punjab. Additional culture laboratories with capacity to perform rapid DST using LPA will be set
up for provinces where disease burden is high and coverage is low. With the planned scale up of
PMDT care, staff will be trained, and a transport system linking all the district DRTB sites to their
local culture and DST laboratories will be established.

The National TB Reference Laboratory will continue its current role with regard to provision of
routine and advanced mycobacteriology services , capacity development, quality assurance,
surveillance of drug resistance to first and second line drugs, new and repurposed drugs, research
including pilot testing of new technologies , and technical assistance for scaling up QA laboratory
services at country level. For proper management of the most complex cases and transmission
studies the NTRL will increase its collaboration with Antwerp and Brussels SNRLs.

To mitigate the risks of exacerbating drug resistance in Pakistan, this plan will engage in ongoing
surveillance for emerging drug resistance to new and repurposed drugs, and collaborate with
established partners at national (AKU) and international level (SRL-Milan and Antwerp) to establish
capacity or ensure access to whole genome sequencing .

5.6 Accelerated implementation of TB/HIV collaborative activities and other

comorbidities
To conform to current international standards of TB care, the N/PTPs, in collaboration with the
National HIV/AIDS Control Program and partners, have planned strategies and interventions that will
increase services to patients diagnosed with TB. These strategies and interventions for a national
scale up of HIV testing in TB patients will be informed by the Punjab province experience where HIV
testing rates in the 2018 TB cohort reached 30%. Anti-retroviral treatment (ART) and co-trimoxazole
preventive therapy (CPT) will be initiated among all TB patients with HIV infection, regardless of CD4
counts. The TB recording and reporting tools will be updated to include essential data on TB/HIV
collaborative activities.
This plan will ensure testing for diabetes of almost all TB patients, through routine random blood
glucose estimations of all TB patients over 20 years. Secondly, operational research will be carried
out to ascertain the prevalence of TB among diabetics that are reachable, in reasonable numbers,
within the health system, public or private, on the basis of which national guidance will be published
on bi-directional screening, recording and reporting for diabetes and TB and increase linkages
between TB services and services for NCDs.

5.7 Operational research and innovation

The M&E Unit, research unit and provinces will collaborate for the 4th National TB Prevalence
survey, which aims to measure the national TB prevalence and also, by enlarging the study size, have
sufficient power to provide prevalence estimates for the provinces. A national consultation
workshop is planned to finalize the methodology for this TB prevalence survey with sub-national
estimates with NTP, WHO and provincial representatives, and the support of WHO TME in early
2020.

The patient cost survey is required by WHO to assess progress against the important indicator of the
number of families experiencing catastrophic expenditures as a result of TB. It will provide evidence

69
for changes to policy and practice, and priority actions to mitigate/eliminate TB patient costs through
enhancing social protection and improving TB service delivery and financing.
The estimates of childhood tuberculosis cases remain weak in Pakistan – the previous prevalence
surveys have not included children. It is suspected that children living in orphanages, public and
private primary schools and Islamic Madaris are more prone to develop TB because of
congested/crowded homes, and low nutritional status. A pilot study to screen for TB among
children living in such institutions in Rawalpindi is therefore planned.

The research unit has been conducting National Structured Operational Research and Training
IniTiative (SORT-IT) courses with financial support of The Global Fund, including work on HIV/AIDS,
and malaria as well as TB.

5.8 Quitting smoking

Tobacco use is a cause of death of around 160,100 Pakistanis every year. Around 24 million adults
currently use tobacco in any form in Pakistan, and there is evidence that a brief behaviour support is
effective in achieving tobacco quit rates of over 40%71 in Pakistan. Further work in field conditions in
KP in Pakistan and Bangladesh in TB patients showed quit rates of over 25% after 12 months. Some
provinces, including KP will therefore continue their efforts to provide appropriate care to TB
patients who smoke to help them quit smoking.

6. Central functions
There are several essential functions that need to be carried out at central level in Pakistan to ensure
optimal coordination between the provinces, regions and territories. These functions are not
covered in the provincial or regional budgets and therefore this Plan includes a separate federal level
budget of US$14.7 million over the four years. The elements covered include:

 Policy and strategy development and guidelines productions and dissemination

 Coordination Capacity development , Quality assurance , surveillance , specialised
mycobacteriology services and coordination of the national laboratory network
 Monitoring and evaluation
 Supervision of provincial/regional programme activities
 Centralised procurement
 Research
 Coordination with external agencies

Policy guidance - The new NTP guidelines will be made widely available in all the health facilities
irrespective of the health sector. Furthermore, the NTP will make available, for all health workers,
clear standard operating procedures (SOPs), algorithms, desk aids and wall charts to help clinicians
at these facilities to quickly arrive at key decisions in the TB diagnostic and management pathway.
LTBI treatment/PET – since the provinces are planning to treat household contacts of 5 years of age
or more, the NTP will clarify their policy on household contacts with no active TB and no HIV
infection receiving LTBI treatment. (It is a conditional WHO recommendation for high TB incidence
countries).
The policy space of new drug regimens for MDR/RR-TB will be an area for rapid change during
2020-2023, the NTP will therefore take responsibility for updating national guidelines DR-TB

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Siddiqi K et al. Action to stop smoking (ASSIST) in Pakistan: a cluster randomised, controlled trial. Ann Intern
Med 2013:158; 667-75.

70
treatment regimens, as new WHO recommendations become available. The emphasis will be on
provision of shorter, all oral regimens of higher efficacy.
Coordination of the national laboratory network, and liaison with the SNRL requires budget not
covered by the provinces, especially as drug resistance testing moves into the genomic era and
whole genome sequencing is now a realistic proposition for TB isolates. In the first instance the
demand may be achievable through collaboration with Milan and Antwerp, but demand may
increase and need to be covered in this budget.
M&E systems – the goal is a digital, case-based data system for TB notification, provider
engagement and patient tracking, with 100% coverage of all TB notifications by 2023. Punjab is
developing its own system. Other regions would need to decide whether to follow Punjab, or
whether they want to benefit from a coordinated national approach.

The biggest challenge for the M&E unit in 2020-2023, in coordination with the Research Unit, will be
the conduct of the 4th National Prevalence Survey, which is intended to provide sufficient sample
size as to make reliable estimates of the burden in each Province. The very provisional budget
estimate was around US$ 7 million.

The case for appropriate operational or implementation research is laid out in 2.4.7 and 5.7..

A more effective central unit requires additional human resources, support staff and vehicles, if they
are to function properly. To address the needs of keeping the Programme Manual up to date,
revising the diagnostic algorithms, expanding the role of chest X-ray in diagnosis, preparing policies,
guidelines and SOPs for LTBI/PET management (especially ensuring that over age 5 children and
adults are now addressed), PPM expansion, involvement of LHWs, the 4th Prevalence Survey, the
new drugs for treatment of MDR/RR-TB, quitting smoking, engagement with NGOs and community-
based organisations, procurement of new equipment, such as X-ray machines, and new diagnostic
machines that will likely come before 2023, cost-effective analyses on active case finding, etc. some
10 or so professional staff will be needed.

The following key actions need to be taken at Federal level:

6.1 Establishing a TB Program Central Unit

As highlighted in the recommandations of the last JPRM, a Central Tehnical Unit for TB Progam
should be established to ensure enssential programmatic management activities, including
coordination with provincial TB programs. Its mission will be clearly defined and the staff positions
and profiles will be specified accordingly. This Central Technical Unit will be responsible for: i) the
formulations of policy, strategy and regulation, ii) the development of guidelines and standards of
practices, iii) the harmonization of the implementation of TB activities across the NTP network, iv)
the coordination with the provinces’ TB Programs, v) the provision of technical support to the
provinces, vi) the resources’ mobilization, vii) the coordination with national and international
partners, viii) the establishment of relevant national working groups to update or rearrange the
existing guidelines or define new approaches, ix) ensuring the availability of a national monitoring
and evaluation framework, x) building capacities for a sound monitoring and evaluation system
across the NTP network, xi) the development of appropriate and standardized data analysis
practices, xii) ensuring TB surveillance and international reporting and building and xiii) sustaining a
momentum for operational research on TB prevention, care and control in Pakistan.

71
6.2 Creating, at national level, a momentum for the development of a multi-sectoral
approach to end TB in Pakistan
TB Program has included the multi-sectoral approach in its policy; however, many stakeholders from
key sectors are not at all aware of the issues of TB in Pakistan and no linkahges have been
establishing with the existing social protection systems at the federal level like Baitulmal, Insaf Sehat
Program or Ehsah program. Very few actions have taken so far to initiate the process multi-sectoral
approach at national level and in Sindh; but these actions have not sustained. To this end, the
following actions will be taken at federal level:
6.2.1 Developing a national strategy to implement a multi-sectoral approach with the technical
support of a national or international consultant. A national workshop will be organized to define the
strategic orientations and a common understanding needed for a sound multi-sectoral approach
adapted to Pakistan context. Relevant representatives of provinces, regions and key sectors will
participate in this workshop. Based on the discussions held in the workshop, a document on the
national strategy will be prepatred and finalized by the consultant. This document will give a strong
visibility to TB issues as prority in the strategic agenda of the other sectors and will be printed and
accessible online in the web site of the MoNHSRC.
6.2.2 Establishing a national steering committee for the development of a multi-sectoral approach to
end TB in Pakistan. This committee will include the representatives of the relevant key sectors that
will play a role in ending TB in the country. It will be chaired by a highly politically influencial person
or a publically well known and highly respected person. This mission will have a clearly defined
mission and well specified work agenda and will meet at least twice a year.

6.3 Maintaining the current functions of the National TB Reference Laboratory through the
following activities:
6.3.1 Provision of routine mycobacteriology/ DST services for patients from ICT,AJK and GB and
for other province/s (Punjab) lacking full DST capacity,
6.3.2 Quality assurance of DST services by organizing annual scheme for EQA of DST services for
Laboratories performing phenotypic and genotypic DST in the country,
6.3.3 Capacity development for culture and DST laboratories through formal training program and
onsite training. Training of MDR clinicians on proper interpretation of Xpert and LPA for clinical
management of cases,
6.3.4 Technical assistance for improving coverage and QA laboratory services including Xpert, LPA,
culture and DST services and effective specimen transport system,
6.3.5 Surveillance of drug resistance: The ongoing surveillance of drug resistance will be continued
and further strengthened; to this end, this following actions will be taken:
6.3.5.1 Surveillance of rifampicin resistance: Currently 260/350 Genexpert machine in public sector
are connected through GXAlert to central server. Provincial staff capacity will be established
for monitoring of Xpert laboratory network, identification of gaps and real-time surveillance
of Rifampicin resistance by districts.
6.3.5.2 Surveillance of prevailing Fluoroquinolone resistancei and analysis of genotypic determinants.
6.3.5.3 Emerging resistance to new and repurpose drugs National drug-resistant TB guidelines are
revised in line with WHO recommendation. Drugs including fluoroquinolone, bedaquiline LNZ
and CFZ are now part of treatment regimen of all drug-resistant TB patients. The NRL has
started the surveillance for bedaquiline susceptibility and first six cases of BDQ resistance are

72
 already reported in Pakistanii. Currently DST capacity for new and repurposed drugs is limited
to NRL. For surveillance of emerging resistance to new and repurposed drugs, all culture
isolates from DRTB patient who fail to convert at three months are/will be tested in NRL. For
surveillance of emerging resistance.
6.3.5.4 The NRL will acquire capacity for Next Generation Sequencing to strengthen drug resistance
surveillance and transmission analysis, training of some staff has already been performed but
has been placed on “hold” for the lack of funding. The acquisition of this technology will
represent an incredibly important resource for proper managing of the most complex cases
and resolve discordance between Phenotypic and genotypic DST.
6.3.5.5 The NRL will collaborate with the supra-national reference laboratory (SRL-Milan, Italy) on
surveillance projects and establish capacity to perform regular molecular and phenotypic
surveillance of emerging resistance and transmission studies research.

6.4 Supporting, from the federal level, the implementation of the mandatory notification of
TB cases in Pakistan
The federal level is responsible for harmonizing and uniforming the implementation of Acts of
Manadatory TB Notification which are approved by the respective provincial assemblies. The
MoNHSRC is also regulating the sale of anti-TB medicines at retail pharmacies to be dispensed at
only in authorized pharmacies declared as (Category “A”) across the country. It is also responsible
for the implementation of Mandatory TB Notification in the Regions of AJK & GB and ICT. The
elctronic mechanism of TB case notification ( see fig. hereafter) will be managed by a central level
call center which will also act as toll free help line (already established with the call number:
0800-88000)

6.5 Enhancing the ongoing momentum for operational research to improve TB prevention,
care and control in Pakistan
The WHO End TB Strategy recognizes research as an important third pillar in achieving the desired
targets and plays a key role in the design of new strategies to ensure optimal utilization of resources

73
and maximize the programme outcomes. The proposed activities of research unit for new funding
request 2021-23 are as follows:
6.5.1 Pakistan SORT – IT Course (Structured Operational Research and Training Initiative):
The journey of national Structured Operational Research and Training IniTiative (SORT IT)
course started in 2016 with support from the Global Fund and led by the international TB
UNION and WHO-TDR. Research unit is following national TB research strategy addressing
programmatic challenges through this initiative by conducting operational researches on
international standards. The courses have proven to be an effective way of building OR
capacity and linking together more than 25 institutions at national & international level i.e.
multiple health programs at the national and provincial level, research organizations &
academia in Pakistan and across the globe. This initiative has resulted in form of approx. 50
published papers, providing local evidence for decision making on TB and other disease
control programmes in open access international peer reviewed journals. This structured
capacity building programme led to changes in policy and/or practice in routine
implementation of a local or national programme, local or national data monitoring,
introduction of new monitoring tool and providing evidence for important programme issues
which incorporated in national strategic policy by i.e. Hospital DOTS linkage, evaluation of
multiple intensified active finding strategies, assessment impact of screeners on TB case
detection, an update on child TB under-reporting, evaluation of Infection control in PMDT
sites, assessment of HIV among TB Patients and prevalence of TB and HV in prisons. The
candidates are followed up on 18th month by The Union as per course guidelines to assess
the policy change. The success of Pakistan SORT-IT course in improving health programme
performance is well recognized72 and acknowledge by WHO-TDR in TDR Global profile for
research capacity strengthening through SORT-IT as unique example in the world. This
initiative deserves to be sustained to address Pakistan health systems bottlenecks and
programme implementations, thus contribute towards achieving universal health coverage.
The course runs over 10–12 months with 3 modules i.e. Module 1 (Six-day module on Research
Questions and Protocol Development); Module 2 (Six-day module on Data Management and Data
Analysis); Module 3 (Seven-day module on Scientific paper writing) with clear milestones and
measurable targets. Failure to fulfil the expected outputs linked to each module implies the candidate
does not return for the next module. Outcomes can be easily measured by assessing the resulting
papers published in open access journals. Training in manuscript writing (Module-III) is a vital
component of SORT-IT course73 and publications in peer- reviewed, open access journals are essential
to disseminate the locally generated evidence to national/ international stakeholders and researchers.
Keeping in view the importance of Module III and publication, these costs requested to be added in
next grant 2021-23.
6.5.2 Patient Cost Survey
TB is associated with significant economic impact and may hamper national development. TB patients
often incur large costs related to illness, as well as for seeking and receiving health care. Such costs are
important access barriers to TB care which can affect health outcomes and increase risk of transmission

72
Fatima R, Yaqoob A, Qadeer E, Hinderaker SG, Heldal E, Zachariah R, Harries AD, Kumar AM. Building sustainable
operational research capacity in Pakistan: starting with tuberculosis and expanding to other public health problems. Global
health action. 2019 Jan 1;12(1):1555215

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Fatima R, Yaqoob A. Strengthening and implementing operational research in National TB Programmes: the Global
Fund's vital role. The international journal of tuberculosis and lung disease: the official journal of the International Union
against Tuberculosis and Lung Disease. 2020 Feb 1;24(2):259.

74
 of disease. One of the three high-level targets of the End TB Strategy is that no TB patients or their
households should face costs due to TB that are catastrophic. The patient cost survey is one of the
priorities identified from the latest Epi review and important indicator for The Global END TB targets.
This will provide an evidence to identify policy and practice implications, and priority actions to
mitigate/eliminate TB patient costs through enhancing social protection and improving TB service
delivery and financing. This study will examine the level and composition of costs incurred by TB‐
affected households during care seeking and treatment; assesses the affordability of TB care using
catastrophic and impoverishment measures; and describes coping strategies used by TB‐affected
households to pay for TB care.
6.5.3 Pilot study for TB screening among the underserved and high risk children in Pakistan:
Every day, up to 200 children lose their lives to TB, which is a preventable and curable disease.
The estimates of childhood tuberculosis cases remained weak because limited surveillance
data from children in many countries. Globally childhood TB cases are under-reported much
due to the difficulty of confirming the diagnosis. This has made it difficult to assess the actual
magnitude of the childhood TB epidemic, which may be higher than currently estimated. The
children living in orphanages, public & private primary schools and Islamic Madaris are more
prone to develop TB because of congested/crowded homes, low nutritional status. A pilot
project is proposed to screen children living in orphanages, public & private primary schools
and Islamic Madaris in Islamabad district to improve TB access and case detection in
underserved and high risk children in Pakistan and to generate evidence for the future scale
up. We are expecting to screen approx. 20000 children in Islamabad and this intervention will
detect above 100 child TB cases.
6.5.4 Consultative Workshop to set national Research Agenda for TB:
Despite being recommended in END TB Strategy on setting health research priorities, there is
little coordination in health research. Diverse actors including the MoH, TB Control Program
at National & provincial level, Principal Recipients (PRs), Sub- Principal Recipients (SRs),
research & academic institutions and other researchers conduct research according to their
own interest. Since there is no research agenda to help focus on national priorities, any
synergies in the research produced are only incidental. A consultative workshop is planned for
setting TB research agenda by consulting all stakeholders related to TB i.e. national &
provincial TB control program, PRs & SRs, MoH and other stakeholder attached with NTP. This
consultative workshop is essential not only to analyze the evidence that exists, but also to
clearly define research questions and collect additional evidence to ensure that NTP national
and provincial programs are effective, efficient, equity promoting, and evidence based. The
intent of this activity will be to establish a national (and provincial) research agenda that will
inform about national health priorities and guide programs to meet these priorities.

6.6 Undertaking the fourth national TB prevalence survey

The last national TB prevalence survey was carried out in 2010/2011. Therefore, after nearly ten
years, it is time to undertake the fourth one to reassess the real TB burden in Pakistan. Given the
high burden of TB in the provinces and the need to adapt TB prevention, care and control
interventions to each of them, the sample size of this fourth TB prevalence survey should have
enough statistical power to make fair estimates not only at the national level but also at least in each
of the four provinces.
An international technical assistance will be needed. The development of survey protocole will be
undertaken at federal level in collaboration with provinces and partners. The coordination and the

75
overall monitoring of survey implementation process will be ensured from the federal level in
collaboration with the provinces, regions and partners.

7. Prioritisation approaches
In all likelihood, the funds to support all the work planned in this document will not be completely
forthcoming. Approaches to prioritisation are thus needed.

First to be excluded should be those activities that are likely not to be cost-effective. When
pressured to find more cases, the mind often moves towards active case finding (ACF). ACF has a
simple logical appeal, but unfortunately, in practice, often fails to deliver the goods. WHO has
already carried out cost-effectiveness simulations (based on real world experience) and provided
recommendations that warn against screening activities in populations with a prevalence of TB of
less than 1%. Evidence to date suggests that much mass screening in Pakistan falls short of this
baseline, and this includes most “conventional camps”, or even “X-ray camps”, as well as more
sophisticated approaches. At the very least, this type of activity needs close monitoring (ideally by a
disinterested central unit) to measure the yield and cost-effectiveness in order to define rapidly its
utility, and contribution to TB case-finding in Pakistan. If it fails to meet its targets within 6 months
of operation, at most, the activity will be terminated and the resources re-allocated to other more
productive activities.

In Pakistan the yield from GPs is so high, and the proportion of GPs engaged in programme activities
so low, that PPM-1 approaches must be of high priority. It has already been pointed out that PPM-1
approaches are significantly more efficient and cost-effective at finding cases than community, or
even targeted, screening.

The JPRM added “if the settings with more than 1% prevalence are confirmed in this evaluation as
hot spots for TB burden, N/PTPs should develop and adapt specific approaches to improve and
strengthen {routine, “passive” case finding,} TB prevention, care and control in these areas.” This is
because case-finding through the conventional approach of enabling the patient to enter a facility of
his/her own accord is usually much more efficient, and lower cost, than more active forms of case
finding.
Case-finding activities of any sort should be focused, when resources are limited, on districts that
are deteriorating, or at risk of doing so – defined by low, and falling, presumptive testing rates, and
low or falling case notification rates. Too much attention should not be paid to case rate
comparisons against the national average. There is too much variation in a country as varied as
Pakistan for that to be valid.
Health facilities with low performance (usually in case-finding, see paragraph above) should be
prioritized for support supervision by the districts’ TB units in order to assess the quality of the
procedures that are used to establish the diagnosis of TB.
Preventive therapy approaches generally turn out to be less cost-effective than case-finding and
treatment. Provincial programmes are beginning to consider a somewhat complicated
programmatic approach to preventive therapy, with registers, adherence monitoring and smart-
phone apps. It should be remembered that stopping or interrupting a course of preventive therapy
does not have the potentially dire consequences of interrupting treatment of active TB, and in high
incidence countries like Pakistan, case-finding and treatment should remain the focus.
Many provinces and regions plan to procure more GeneXpert machines in order to make them
accessible to patients. We already know that most people diagnosed by Xpert, are diagnosed in

76
their own facility. Thus GeneXpert machines seem accessible only to those nearby. However, an
efficient sputum transport mechanism, proposed by several provinces and regions, would obviate
the need for many more Xpert machines. Any proposed procurement should be looked at critically.
Human resources are expensive. Some provinces have plans to hire a lot of staff, which should be
examined carefully when resources are restricted.

8. Modelling results of achievements with proposed inputs

8.1 Overview of the TIME model
TIME Impact is an epidemiological transmission model available within the open-source Spectrum
suite of policy models. TIME is used by TB policymakers and national TB programs (NTPs) to develop
strategic responses and strategies for TB and to produce projections that inform funding
applications. The model has been used in many TB settings, including in countries where TB is driven
by HIV, by weak health systems, countries with high MDR burden, and countries where TB programs
depend on a high level of private sector involvement. The Estimates component of TIME was used by
the Global TB Programme (GTB) to produce estimates for HIV-TB burden towards the Global TB
Report.

The TIME model reflects key aspects of the natural history of TB including primary and latent
infection, reinfection, and reactivation of latent TB. Smear positivity, negativity, and smear
conversion are explicitly handled in the model. Like all models implemented in Spectrum, TIME is
demographically explicit and operates on the latest demographic estimates published by the UN
Population Division (UNPD) as the World Population Prospects, currently in its 2017 revision. TIME
has additional structure for HIV/ART that mimics the structure of the Spectrum AIDS Impact Model
(AIM) and directly uses its HIV programmatic data. The model also accounts for the characteristics of
paediatric TB, treatment history, and drug resistance. TIME includes two generic strains by MDR
status: susceptible and resistant to treatment. Resistance can be acquired during treatment or by
direct transmission, at rates that distinguish it from the susceptible TB type.

TB control interventions can be represented in TIME by changing model parameter values directly
over time, or by making use of the explicit intervention structure available for some general TB
interventions. For example, users can opt to represent changes in the diagnostic algorithm by
manually changing net diagnostic sensitivity and specificity over time, or by making use of a
Diagnostic Algorithm Tool (DAT) which allows users specify the mixture of diagnostic pathways over
time. Other explicit interventions include household contact investigation and preventive therapy
for children <5 and for adults 15+ by HIV/ART strata (HIV-, HIV+ not on ART, and HIV+ on ART).

8.2 Model calibration

Like all models, TIME must be calibrated to historical epidemiology such as estimates of incidence
and prevalence, and programmatic outcomes such as notifications, and numbers of TB suspects
tested by various methods, and numbers successfully treated. Calibration involves collaboration with
NTP experts in order to gather data, understand the history of the epidemic and the programme
response, and assess the reliability of various estimates and reported data. A good calibration will
reproduce various aspects of the epidemiology and programme data independently.

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Figure 11. Key calibration results. Calibration targets are shown in gold. Top left shows a good fit
to WHO Global TB Programme (GTB) estimates for incidence per 100,000 population. Top right
shows total prevalence in the model (black line) is highly relative to the most recent prevalence
survey estimate from 2011-12; however, total prevalence agrees with a more recent estimate.
Bottom left shows that the model significantly exceeds GTB estimates of per capita mortality.
Bottom right shows good agreement with total notifications, accounting for an estimated 20%
ratio of underreporting.

8.3 Model scenarios

We present results for three scenarios:

 S0: Scenario 0 is simply the calibrated file with all parameters fixed after 2019. taken as a
counterfactual for comparison.
 S1: Scenario 1 involves scale up of preventive therapy, increased GeneXpert coverage in the
public sector, increased treatment coverage and treatment success, and an increase in the
overall rate of screening.
 S2: Scenario 2 retains the coverage increases for S1, while expanding the scope of current
ACF programs based on CXR and Xpert.

In all cases, parameter values were linearly increased over the period 2019-2023 (first increase in
2020) in order to achieve stated targets for total number of TB cases successfully treated and total
numbers on preventive therapy over the period for S1 and S2. Specific values are given in Table 19
below.

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Table 19. Scenario definitions.

2019 2023 (S1) 2023 (S2)

Screening rate, SS+ 155 180 215
Screening rate, SS-
HIV- 109 180 215
HIV+ 124 180 215
Preventive therapy coverage
Child contacts 5.7% 95% 95%
HIV+ adults 0% 95% 95%
HIV- adults 0% 1.8% 1.8%
DS-TB
Linkage to care 90% 95% 95%
Treatment success 94% 95% 95%
DR-TB
Linkage to care 85% 95% 95%
Treatment success 64% 70% 70%
Coverage of GeneXpert 40% 67% 67%
Coverage of ACF pathway 12% 12% 24%

Scenario results are shown in Table 2 below. Parameter values for S1 and S2 were chosen in order to
achieve the cumulative targets of 1.6m (S1) and 1.75m (S2) TB cases successfully treated, and 1.9m
total on preventive therapy (both S1 and S2).

Table 20. Key results from model scenarios

S0 S1 S2
TB cases successfully treated 1,471,678 1,602,592 1,754,389

Total number on preventive therapy 75,015 1,891,644 1,974,733

Child contacts 75,015 890,077 974,580
HIV+ adults 0 595,901 595,902
HIV- adults 0 405,666 404,251

Incident TB cases 2,024,105 1,740,490 1,580,677

Notified TB cases 1,571,414 1,799,931 1,967,784
TB Deaths, adjusted to 2018 estimate 167,403 138,057 121,860

Incidence per 100,000 in 2023 235 171 138

% reduction, relative to 2015 12% 36% 48%
Prevalence per 100,000 in 2023 295 174 118
% reduction, relative to 2015 15% 49% 66%

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Figure 12. Total number of presumptive TB suspects tested, by sector, over the period 2020-2023.
Increased screening rates lead to more presumptive TB suspects tested in S1 (7.9m) and S2 (8.6m)
relative to S0 (7.3m) over the period. The expansion in ACF coverage is also evident in S2.

Figure 13. Total number of smear microscopy and GeneXpert tests, by scenario, over the period
2020-2023. Increases from S0 to S1 are primarily driven by increased screening rate, leading to
more presumptive TB suspects tested. The increase in GeneXpert tests from S1 to S2 is due to the
expansion of ACF pathways based on chest x-ray followed by GeneXpert, with increase in tests
overall driven by the further increase in number of presumptive TB suspects tested.

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9. The Monitoring and Evaluation Plan
1 Introduction
This monitoring and evaluation plan is the framework that defines the indicators aimed at assessing
the achievement level made to reach the goal(s), objectives and targets specified in the NSP. It also
will:
 monitor the progress made in the implementation of planned activities and in delivery of
services,usually on a continuous basis;
 evaluate the progress made towards the intended goal(s), objectives and targets,
 evaluate and make recommendations specifically on the M&E system itself.
It is intended to be fully consistent with the other components of the P/RSPs.
As of January 10 2020, all provinces and regions, apart from KP and Sindh, have simply listed the
original indicators to be used, but have not yet populated the tables with baseline data or targets.
KP has listed just the top ten WHO End TB indicators, together with the baseline figures, but without
the annual targets. Sindh has focused on the treatment targets for all types of TB, with baseline and
annual targets. The list below in this national plan, developed by the NTP staff, M&E Unit, and WHO,
is intended to be the template for the provincial and regional plans. Therefore all provinces and
regions need to deelop further their M&E Plans. This NSP should help guide them in so doing.

2 Description (summary) of the information system for TB

2.1 The Health Information context
The Health Information Management System in Pakistan is still fragmented. There are numerous
health information and disease surveillance systems that are currently not communicating with each
other, although efforts are underway to integrate these systems. Operational systems in place
currently include District Health Information System 2 (DHIS2) and information systems that serve
vertical programs such as maternal, neonatal and child health (MNCH), HIV/AIDS, TB, the Expanded
Program of Immunization (EPI), malaria, dengue, service statistics, and the Human Resource
Management Information System, among others. Most of these data systems do not capture
information from the private sector. To address the multiplicity of data systems and the vertical
nature of these systems, the MoNHSRC recently established a technical unit, the Health Planning,
Systems Strengthening and Information Unit to revitalize the National Health Information and
Resource Centre. One major task of this unit will be to work towards integrating the various
information systems and to produce annual health reports in addition to reporting internationally on
the progress Pakistan is making on Sustainable Development Goals (SDG).

2.2 Monitoring and Evaluation for TB

The NTP has developed an adequate information system to monitor TB notifications and the
implementation of TB prevention, care and treatment activities and to evaluate their outcomes. This
system includes:
i) Presumed TB Patients’ register,
ii) Request form for sputum examination,
iii) TB microscopy and Xpert register,
iv) laboratory culture and DST request form,
v) TB culture and DST register
vi) TB treatment register,
vii) facility-based patient treatment card,
viii) patient identity card,
ix) sputum conversion reporting form,
x) referral form,

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 xi) quarterly TB registration reporting form,
xii) quarterly treatment outcome reporting form, and
xiii) quarterly TB drugs’ inventory reporting form.

Data on TB notification and treatment outcomes are collected in the BMUs and reviewed and
compiled at district level, then at the province and NTP Central Unit levels. For the information on
TB contact investigation activities, the facility-based patient treatment card includes a small section
where this information can be collected. To monitor and evaluate PMDT activities, a specific
registration system, including a case-based computer database, has been developed and
implemented in the PMDT sites.
The District Health Information System 2 (DHIS2) is being implemented in Pakistan, but the NTP
information system has not yet been linked to this system. The NTP information system needs to be
linked to this DHIS2.

2.3 Strengths (derived from the JPRM)

 The required definitions of TB cases and treatment outcomes are in general well understood
and used by the health staff in charge. The registers are generally adequately filled, and
include, most of the time, the required information. The quarterly reports on TB notification
and treatment outcomes are filled in almost all BMUs and include detailed information.
 In many districts, but not all, the data included in the quarterly reports are reviewed and
discussed in the district quarterly meetings with the staff of the relevant BMUs.
 Data on TB activities undertaken in the private sector are collected through the NGOs and
included subsequently in the NTP information system.
 The NTP’s information system has succeeded in collecting a significant amount of data that
are used for advocacy purposes, epidemiologic surveillance and programmatic management,
including supervision activities. The results of data analysis contribute to identifying
hypotheses for operational research.
 The NTP prepares and issues every year an Annual Report that gives TB notifications, TB
service outcomes, and interventions that have been developed and implemented. This
report is widely distributed and forwarded to those who need to be kept informed.

2.4 Weaknesses
 Even though the NTP has issued a register to specifically identify presumed TB patients, it is
not always available in BMUs, and even when it is, information on patients identified as
presumed TB cases is not always collected. In addition, the NTP has not issued clear
guidance on how to use this register, especially how it should be linked to the TB laboratory
register and OPD register.
 The request form for bacteriological examination is not standardised. In some health
facilities, the request forms for sputum examination do not include the items to collect
information related to a request for Xpert testing. Different TB laboratory registers are
used, some are old, while others are more recent and include the Xpert component as
recommended by WHO.
 Given the low proportion of previously treated patients among all registered TB cases in
some districts and provinces (Balochistan , Khyber Pakhtunkhwa and Punjab), a
misclassification of retreatment patients as new TB cases is probable in these settings. The
high proportion of “other previously treated TB patients” among all retreated TB cases in
some provinces (Gilgit Baltistan, Sindh and FATA) suggest that the definitions of the different
categories of retreatment TB cases are probably not fully understood and, therefore, not
appropriately used by the health staff of BMUs.

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  Different TB treatment registers are used in the BMUs. The most recent of them includes
unnecessary columns for CXR, especially at the 2nd and 5th months of treatment.
Regardless of the age of the TB treatment registers, no columns are included on HIV
screening, ARV treatment or co-trimoxazole provision. In some BMUs, there is a separate
register on HIV screening and treatment, with ARVs and co-trimoxazole.
 As highlighted above:
o the component on contact investigation included in the facility-based patient
treatment card does not allow the collection of all the relevant data on TB contact
investigation activities and preventive treatment,
o the N/PTP has not yet established a registration system for preventive treatment
and
o no indicators have been defined to monitor the implementation of TB contact
investigation activities, or TB preventive treatment, nor to evaluate their outcomes.

Although significant efforts have been made through the SORT-IT Initiative, capacities to undertake
in-depth data analysis are still sub-optimal, especially at provincial level. This is reflected by the lack
of consistency in some of the reported data.

2.5 JPRM Recommendations relevant to this NSP

 In the training on basic TB, a focus should be made, on the definitions of TB cases and
treatment outcomes, including on the previously TB treated patients and their various
categories.
 In supervision, more data quality checks are needed from the various registers and compiled
reports. The quality and the consistence of the data that are compiled at province and
national levels should be checked and assessed by the relevant staff at PCP and NTP Central
Unit levels.
 The NTP should clearly define indicators to monitor the implementation of TB contact
investigation and to evaluate its outcomes. The following indicators were proposed:
Monitoring indicators focusing on contact management bearing in mind the need to address contacts
of all ages
 The ratio of the number of index cases whose contacts were investigated divided by the
number of TB cases registered in the TB treatment register who meet the criteria of a TB
index TB case. In the ideal situation, this ratio will be slightly less than 1.
 Proportion of identified contacts who were screened and assessed for TB.
 Proportion of contacts aged less than 5 years with no active TB who were prescribed IPT. If
the NTP policy considers that IPT should be prescribed to contacts aged more than 5 years
with LTBI, then the proportion of this category of contacts who were prescribed IPT will
need to be included in the monitoring indicators.
Evaluation indicators
 Prevalence of active TB among the contacts who were screened and assessed. The
prevalence should be calculated, if possible, for each form of TB (BCPTB, CDPTB, EPTB).
 Proportion of TB cases identified through contact investigation among TB patients registered
in the TB treatment register. This proportion should be also calculated, if possible, for each
form of TB.
 Proportion of contacts aged less than 5 years with no active TB who completed IPT. If the
NTP policy considers that IPT should be prescribed to contacts aged more than 5 years with
LTBI, then the proportion of this category of contacts who completed IPT will need to be
included in the evaluation indicators.

83
  The NTP should also define clear indicators to monitor the implementation of LTBI
management and to evaluate its outcomes.

2.6 Moving ahead

This NSP should move towards establishing a fully digital, case-based, web-based data system for TB
notification, provider engagement and patient tracking, with 100% coverage of all TB notifications by
2023. This is essentially a function that needs to be centrally led by the NTP M&E Unit.

To take full advantage of such a digital system, the relevant provincial staff should be further trained
on the methodology of data analysis, using, for example, the Data for Action Course that has been
developed by the IUATLD.

3. Targets and indicators for the NSP

INDICATOR Baseline - Baseline 2020 2021 2022 2023
2018 -2019
1 DSTB treatment 63% 50% 66% 71% 73% 75%
coverage
N Number of new and 358592 281620 384511 420556 443918 464840
relapse cases that
were notified and
treated, divided by
D the estimated 567392 567450 580987 592405 604058 615945
number of incident
TB cases in the same
year, expressed as a
percentage.
2 DSTB treatment 33% 36% 38% 39% 40% 41%
coverage-TB cases
notified private
provider
N Number of new and 118261 101179 146989 165279 177615 190609
relapse cases that
were notified and
treated by private
providers , divided by
D Number of total new 360018 283392 386176 422463 445859 467036
and relapse cases
that were notified
and treated.
3 DSTB treatment 80% 80% 81% 81% 81% 81%
coverage-
Pulmonary TB (PTB)
N Number of new and 289254 227206 312679 344197 360473 377890
relapse PTB cases
that were notified
and treated, divided
by

84
D Number of all 360018 283392 386176 422463 445859 467036
(PTB+EPTB) new and
relapse cases that
were notified and
treated.
4 DSTB treatment 12% 14% 13% 13% 14% 15%
coverage- Child hood
PTB
N Number of new and 36188 33300 43212 49631 54738 61295
relapse CHPTB cases
that were notified
and treated, divided
by
D Number of All new 306592 244810 336061 370210 388796 408920
and relapse PTB
cases that were
notified and treated.
5 DSTB treatment 48% 50% 50% 57% 61% 65%
coverage-
Bacteriological
confirmed PTB
N Number of new and 139326 114519 159181 197109 223521 246962
relapse
bacteriologically PTB
cases that were
notified and treated,
divided by
D Number of new and 292542 230423 315638 347458 364235 382003
relapse PTB cases
that were notified
and treated.
6 DSTB treatment 98% 124% 92% 92% 92% 92%
success rate
N Number of notified 349218 350773 347784 383252 401126 421249
TB patients who
were successfully
treated.
D Number of new and 355953 282296 376903 414376 437508 458415
relapse cases that
were notified and
treated
7 DSTB services 9% 10% 47% 59% 61% 62%
coverage in BHUs
N Number of Primary 589 609 2860 3573 3678 3763
health facilities
(BHU) offering TB
diagnostic and/or
treatment services.
D Total number of 6372 6372 6056 6056 6056 6056
Primary health
facilities (BHU)

85
8 DSTB services 255% 255% 368% 111% 164% 165%
coverage in Private
sector
N Number of Private 3071 3071 4962 10075 14858 14924
GP engaged in TB
control
D Total number of 1202 1202 1350 9050 9050 9050
Private GP
registered.(Incompletel
data)
9 DRTB treatment 44% 44% 65% 74% 79% 81%
coverage
N Number of RR/MDR 3195 2688 5928 7745 9376 10582
TB cases that were
notified and treated,
divided by
D Estimated number of 7300 6158 9055 10455 11832 13090
incident DRTB cases
among
bacteriologically
confirmed PTB cases
notified in the same
year, expressed as a
percentage.
10 DRTB treatment 65% 65% 69% 71% 78% 86%
success rate
N Number of notified 1918 1767 4069 5509 7328 9058
RR/MDR TB patients
who were
successfully treated.
D Number of RR/MDR 2952 2739 5873 7745 9376 10582
TB cases that were
notified and treated
11 DRTB patients- social 37% 36% 63% 83% 83% 83%
support coverage
N Number of notified 1033 828 3706 6406 7757 8771
RR/MDR TB patients
who received social
support during
treatment
D Number of RR/MDR 2767 2330 5928 7745 9376 10582
TB cases on
treatment
12 DRTB services 32% 31% 37% 76% 76% 76%
coverage
N Number of 29 29 35 74 74 74
Districts(population
>1M) having
minimum of one
functional DRTB
treatment site

86
D Total number of 90 93 95 97 97 97
district (Population >
1M)
13 Percentage of TB- 0% 0% 0% 0% 0% 0%
affected households
that experience
catastrophic costs
due to TB
N Number of people 0 0 0 0 0 0
treated for TB (and
their households)
who incur
catastrophic costs
(direct and indirect
combined), divided
by
D the total number of 363940 285656 391075 427590 446158 467530
people treated for
TB.
14 Percentage of new 28% 42% 71% 74% 76% 80%
and relapse TB
patients tested using
a WHO-
recommended rapid
diagnostic (WRD) at
the time of diagnosis
N Number of new and 99901 118027 275687 315195 341691 373694
relapse TB patients
tested using a WRD
at the time of
diagnosis, divided by
.
D total number of new 360692 279282 389153 424667 447542 468178
and relapse TB
patients, expressed
as a percentage.
15 Latent TB infection (LTBI) treatment coverage
15 Latent TB infection 69% 49% 24% 49% 64% 66%
a (LTBI) treatment
coverage in <5yrs HH
contact of B+PTB
N Number of children 5949 4172 46042 149607 213519 231867
aged <5 years
contacts of people
with bacteriologically
confirmed TB
enrolled on LTBI
treatment divided by
the
D number children 8586 8590 194968 304986 331721 349551
<5yrs HH of B+ PTB

87
 eligible for
treatment,
15 Latent TB infection 3% 16% 24% 33% 49% 52%
b (LTBI) treatment
coverage in people
>5ys HH contact of
B+PTB
N Number of people 387 2021 110057 207836 336722 370545
aged >5 yrs who are
household contact of
people with
bacteriologically
confirmed PTB,
enrolled on LTBI
treatment divided by
D Number of people 11483 12500 458074 635686 682247 713835
aged > 5yrs who are
household contact of
people with
bacteriologically
confirmed PTB
15 Latent TB infection 85% 115% 77% 85% 87% 87%
c (LTBI) treatment
coverage in people
living with HIV
N Number of people 662 874 703 1159 1380 1393
newly enrolled in HIV
care enrolled on LTBI
treatment divided by
D Number of eligible 777 758 909 1361 1579 1596
people newly
enrolled in HIV care
(incomplete data)
16 Contact 182% 201% 95% 96% 97% 97%
investigation
coverage
(Incomplete data in
denomoniatorhence,result
ing in massive proportion
in 2018-19)
N Number of contacts 137900 152237 602226 679561 712741 744116
of people with
bacteriologically
confirmed TB who
were evaluated for
TB, divided by .
D the Total number 75824 75806 636691 709934 737086 768994
eligible contact of
Bacteriologically
conformed TB
expressed as a
percentage.

88
17 Drug-susceptibility testing (DST) coverage for TB patients
17 Drug-susceptibility 45% 68% 70% 70% 57% 73%
a testing (DST)
coverage for New TB
patients
N Number of 113011 68470 100561 122049 141549 159419
bacteriologically
confirmed New TB
cases with DST
results for at least
rifampicin, divided by
D Total number of 253900 100647 144345 174446 249228 218056
New bacteriologically
confirmed TB cases
in the same year,
expressed as a
percentage
17 Drug-susceptibility 80% 80% 84% 84% 85% 85%
b testing (DST)
coverage for
previously treated
TB patients
N Number of 25172 9311 14424 17452 20148 22079
previously treated
bacteriologically
confirmed TB cases
with DST results for
at least rifampicin,
divided by
D Total number of 31303 11705 17221 20764 23770 25998
previously treated
bacteriologically
confirmed TB cases
in the same year,
expressed as a
percentage
17 Second line Drug- 93% 95% 94% 94% 94% 94%
c susceptibility testing
(DST) coverage for
RR/MDR TB
N Number of RR/MDR 5719 2751 5370 6906 8118 9142
TB patients with
DST results for
second line drugs
D Tota Number of 6174 2898 5734 7371 8649 9729
RR/MDR TB patients
enrolled on second
line treatment
18 Treatment coverage, 127% 78% 86% 81% 81% 82%
new TB drugs

89
 (incomplete baseline
data)r
N Number of TB 916 886 3412 4406 5288 5948
patients treated with
regimens that
include new
(endorsed after
2010) TB drugs,
divided by
D the number of 719 1133 3990 5430 6527 7253
notified patients
eligible for treatment
with new TB drugs,
expressed as a
percentage.
19 Documentation of 21% 47% 55% 73% 73% 74%
HIV status among TB
patients
N Number of new and 75401 133622 210153 307102 324859 343386
relapse TB patients
with documented
HIV status, divided
by the
D The number of new 360023 285761 384669 419835 442059 464039
and relapse TB
patients notified in
the same year,
expressed as a
percentage.
20 Case fatality ratio 1% 0% 0% 0% 0% 0%
(CFR)(incomplete data)
N Number of TB deaths 687 226 0 0 0 0
divided by
D estimated number of 91657 93384 96301 103359 106180 110836
incident cases in the
same years,
expressed as a
percentage.

21 Domestic fund 386% 142% 199% 0% 0% 0%

contribution
(Incomplete data)
N Total domestic 255 107 190 0 0 0
commitment (PC1)
for same year
D Total Need 66 76 95 133 122 128
expressed in
strategic plan ( In
US$)

90
 22 Domestic fund 111% 92% 96% --- --- ---
releases
N Amount (PKR) 493 550 593 --- --- ---
released
D Total domestic 445 595 615 --- --- ---
commitment (fund
allocated) for fiscal
year

23 Domestic fund 40% 33% 10% 10% 10% 11%

contribution
N Number of FLD 127800 83600 35938 39399 42973 46663
courses procured
through domestic
funds
D Total First line 318749 254547 365953 398874 414923 432288
courses acquired in
fiscal year

24 Change in Control --- --- 88% 70% 70% 70%

strategies resulting
from research
Number of research --- --- 7 7 7 7
conducted leading to
policy change
Total number --- --- 8 10 10 10
Operation research
conducted

4. Surveys planned for 2020 – 23

The M&E Unit, research unit and provinces will collaborate for the 4th National TB Prevalence
survey, which aims to measure the national TB prevalence and also, by enlarging the study size, have
sufficient power to provide prevalence estimates for the provinces. Most provinces and regional
have included a prevalence survey in their plans as the most practical and precise way of estimating
the current true burden of TB in Pakistan. Not all have mentioned collaboration with the national
level on a national survey, but this is the only practicable and cost-efficient approach. A national
consultation workshop is planned to finalize the methodology for this TB prevalence survey with
sub-national estimates with NTP, WHO and provincial representatives, and the support of WHO TME
in early 2020. An outline budget of about US$6.7 million has already been developed.

The patient cost survey is required by WHO to assess progress against the important indicator of the
number of families experiencing catastrophic expenditures as a result of TB. It will provide evidence
for changes to policy and practice, and priority actions to mitigate/eliminate TB patient costs
through enhancing social protection and improving TB service delivery and financing.

The estimates of childhood tuberculosis cases remain weak in Pakistan – the previous prevalence
surveys have not included children, and the proposed survey will not do so either. It is suspected
that children living in orphanages, public and private primary schools and Islamic Madaris are more
prone to develop TB because of congested/crowded homes, and low nutritional status. A pilot study
to screen for TB among children living in such institutions in Rawalpindi is therefore planned.

91
10. Operational Plan
The provinces and regions are at different stages in the preparation of operational plans: Punjab has
a detailed Operational Plan, but, not surprisingly has not yet identified sources of funding (and costs
are not stated in the Operational Plan but are very clear in the Budget Plan). Sindh and KP have
simply listed their proposed activities and sub-activities, with none of the detail required in an
operational plan – see below. Balochistan’s Operational Plan is detailed and clear, missing only the
sourceof funding. AJK, FATA, GB and ICT have operational plans that clearly link the activities and
sub-activities under the appropriate strategic interventions and objectives (as suggested by WHO),
but they are vague on the timing and the source of funding – and their costs are in the Budget Plans
only.
According to WHO, the operational plan is an important component of the NSP and should focus on
the activities to be implemented. It must be fully consistent with the core plan, budget plan,
monitoring and evaluation plan, and technical assistance plan. However, at this point in the
preparation of P and RSPs in Pakistan, it makes sense to hold off on detailed operational planning
until the budget envelope in each province and region is clearer since the total budgets significantly
exceed the anticipated overall funding.
WHO further recommends that the operational plans should specify detailed information, by
quarter, on the activities and sub-activities that need to be implemented at least for the first year of
the period covered by the NSP. “The implementation of the activities for the remaining years of the
NSP can be detailed subsequently.

For the first year, on a quarterly basis and for each activity or sub-activity clearly specified, the
following information should be identified:
 the dates or the period when it will be implemented;
 the setting where it will be implemented;
 the person/institution that will be responsible for its implementation;
 the cost inherent in the implementation of this activity or sub-activity as calculated in the
budget plan;
 the source of funding that will cover this cost;
 the process indicator that will be used to monitor the implementation of the activity or sub-
activity.”

Technical assistance components listed in the operational plans should be further developed in a
specific TA Plan, again, under the relevant objective, intervention or activity or sub-activity.

Consistency should be assured with the operational plans of other programmes such as HIV/AIDS
programmes, maternal and child health programmes or noncommunicable disease programmes.

92
11. Technical assistance (TA) plan

1. Introduction
The NTP and P/RSPs may wish to engage providers of technical assistance (TA) to support the
adoption and implementation of interventions. TA at regional or provincial level should be
coordinated nationally to avoid ineffeiciencies, since needs are similar across provinces and regions.
TA activities should be closely linked to the Operational Plan on which they should be based.
According to WHO, the TA Plan provides detailed information on the technical assistance required
for the strategic interventions and activities, as identified in the operational plan.

Like the operational plan therefore, the TA Plan should be established for the first two years of the
NSP, and should be based on provincial and regional needs. For the remaining years, the technical
assistance needs to be identified as far as possible. Technical assistance can be provided by
national as well as international experts.

2. Areas indicated for TA by the JPRM

The JPRM suggested the following areas for TA at the national level:

1. Data driven supervision to support the use of data to drive interventions at the local level.
This is intended to support the need for district and tehsil level staff to understand, analyse and use
their own data for local decision-making. The International Union against TB and Lung Disease runs
international courses on “Principles of Tuberculosis Care and Prevention: Translating Knowledge to
Action” which can be tailored for individual countries74. Pakistan may wish to coordinate such TA
from the central level for the provinces

2. DR-TB decentralization and adoption of new regimens

The management of DR-TB is complex, and will very probably undergo significant advances in the
coming years especially in treatment75. International TA may well be desirable.

3. The development of operational guidelines for sputum transport

The expansion of properly organised and effective sputum transport is a major priority and
mentioned in almost all P/RSPs (see below), however, none of these has a convincing solution. Yet,
the Global Fund is prepared to invest in radical solutions. At the same time, local staff correctly
point out that the variation in local conditions in Pakistan is immense and therefore “one-size-fits-
all” is not going to be a solution. However, analysis and organisation of effective approaches can be
addressed centrally and different approaches tried in different places, until sufficient successful
examples are found that will solve the problem.

4. Further development of TB laboratory capacity, especially the introduction of genome

sequencing procedures.
1. Development of operational guidelines for preventive treatment of TB

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Heldal E, Dlodlo RA, Mlilo N, Nyathi BB, Zishiri C, Ncube RT, Siziba N, Sandy C. Local staff making sense of
their tuberculosis data: key to quality care and ending tuberculosis. Int J Tuberc Lung Dis. 2019 May
1;23(5):612-618. doi: 10.5588/ijtld.18.0549
75
WHO. December 2019. Rapid Communication: Key changes to the treatment of drug-resistant tuberculosis.
WHO, Geneva.

93
Work on this issue is already under way.

3. Areas for TA indicated in the provincial/regional plans

The four regions/territories have developed sketchy TA Plans, while Baluchistan a has a more
considered and detailed Plan. Punjab, Sindh and KP have yet to prepare a TA Plan, although Punjab,
in its Operational Plan, has declared a need for TA to support the Prevalence Survey, and to help
drafting a law to prevent the sale of over-the-counter (OTC)anti-TB drugs.
Understanding of what needs to be in a TA Plan is still basic. The TA Plans at present include
problematic areas which could relatively easily be addressed by central discussion and coordination.
What should be included will be addressed below using WHO guidance76. However, some important
common needs are emerging:

3.1 Procurement of purified protein derivative PPD.

This is common to AJK, GB and ICT and represents a problematic area which is caused by low stocks
internationally, but a coordinated national approach could be organised centrally, in collaboration
with the Global Drug Facility (GDF). Specific TA beyond routine GDF support probably not required.

3.2 Procurement of digital XR machines

This is common to AJK, FATA and ICT and may be a challenge for the smaller regions, but a
coordinated national approach could be organised centrally, with support from WHO.

3.3 Procurement of Xpert machines

Common to AJK and ICT. Similar to 3.2 above, and in any case there is considerable experience in
Pakistan already in procurement of these machines. Perhaps acase for inter-regional/provincial TA.

3.4 Mobile applications for case notification and contact tracing

Common to AJK, Balochistan and ICT. Mention is also made of “case based android TB case
notification applications …for reporting GPs” in the Core Plan of Punjab and a similar mention in
Sindh. This may be another area for inter provincial/regional TA.

3.5 Legal drafting of Bills

Punjab’s Core Plan mentions the need for TA to draft a Bill against OTC sales of ATT medicines, while
GB needs help for a Bill on Mandatory Notification. The latter has already been achieved in a
number of provinces and regions and hence perhaps is another area for inter provincial/regional TA.

3.6 Mapping of private providers

The need was expressed by FATA and ICT. Again, this has already been achieved in some
provinces/regions and could thus be another area for inter provincial/regional TA.

4. Recommendations for finalising TA needs

Identification of TA needs is clearly a provincial/regional responsibility. KP, Punjab and Sindh need to
develop their TA Plans, while the regions may wish to revise theirs. It is most sensible to start
defining those needs in the process of preparing the operational plans. Then, national level review
and coordination of the final listing of TA needs is essential to avoid repetition and inefficient
organisation of support, especially for the regions.

76
WHO, 2015. Toolkit to develop a national strategic plan for TB prevention, care and control: methodology
on how to develop a national strategic plan. WHO, Geneva.

94
As recommended by WHO, the following information must be specified for each strategic
intervention or activity that needs technical assistance:
 a brief description of the terms of reference for the technical assistance required, including
the specification of deliverables;
 a brief description of the profile/expertise of the consultant who will ensure the technical
assistance;
 the identification of the entity responsible for the implementation of the intervention or
activity;
 the timeframe to carry out the technical assistance;
 the estimated cost of technical assistance (including consultancy fee, travel, per diem) as
 calculated in the budget plan;
 identification of the source of funding, if available;
 identification of the funding gap that needs to be closed in the event that there is no
financial
 source to cover the cost of the technical assistance.

95
12. Contingency Plan for Emergencies, Natural Disasters etc.
Background
Pakistan is prone to earthquakes, floods and droughts, as well as man-made, military interventions
by State, or Non-State actors that threaten the security of the general population, within or just
outside the national borders, and therefore can give rise to mass displacement of populations within
the country. Such displacement will obviously affect patients, their families, and indeed, health
staff, including those responsible for TB care and prevention. An Emergency Plan therefore initiates
contingency planning for such events. It should address the issues relating to the care of patients
with tuberculosis (TB) and controlling the spread of the disease in refugee and displaced
populations.
A major problem with IDPs and refugees, whether they are in a formal camp or not, is that they may
not be able to access national or NGO health services. Mechanisms providing services for the stable
population may not apply. IDPs, unlike refugees, may not have the same level of protection from
the international community and national authorities may not address their needs. It is therefore
vital that efforts are made to reach this vulnerable population and include them in health care
services. Increased collaboration between the NTP and NGOs can increase population coverage and
improve the efficiency with which TB care and control activities are implemented in displaced
populations. Proactive measures should be taken, including the use of community health workers
and mobile clinics.

A patient suspected of TB must be managed according to the International Standards for

Tuberculosis Care.
At present, the only RSP to address this emergency situation is FATA’s. Even there, however, the
details are sketchy. Planning for such emergencies needs to take place at both the Central and
Provincial/Regional levels. It should address internally displaced populations, refugees, and asylum
seekers, whether in camps or not.
A logical approach to the development of an Emergency Plan would be for the central level to
develop a template that addresses actions required at central level and provides a format for the
provinces and regions to follow. This then needs to be coordinated with the national, provincial and
regional stakeholders likely to be involved in any emergency, namely the military, Red Cross,
UNICEF, World Food Programme, national and international NGOs and CBOs involved in this type of
work, such as MSF, as well as the NTP and WHO/WCO. The best available international guidance is
Chapter 7 of the 2007 Tuberculosis care and control in refugee and displaced populations: an
interagency field manual.

i
Zignol M, Dean AS, Alikhanova N, Andres S, Cabibbe AM, Cirillo DM, Dadu A, Dreyer A, Driesen M, Gilpin C,
Hasan R, Hasan Z, Hoffner S, Husain A, Hussain A, Ismail N, Kamal M, Mansjö M, Mvusi L, Niemann S, Omar SV,
Qadeer E, Rigouts L, Ruesch-Gerdes S, Schito M, Seyfaddinova M, Skrahina A, Tahseen S, Wells WA, Mukadi YD,
Kimerling M, Floyd K, Weyer K, Raviglione MC. Population-based resistance of Mycobacterium tuberculosis
isolates to pyrazinamide and fluoroquinolones: results from a multicountry surveillance project. Lancet Infect
Dis. 2016 Oct;16(10):1185-1192. doi: 10.1016/S1473-3099(16)30190-6. Epub 2016 Jul 7. PubMed PMID:
27397590; PubMed Central PMCID: PMC5030278

ii
Ghodousi, A., Rizvi, A. H., Baloch, A. Q., Ghafoor, A., Khanzada, F. M., Qadir, M., … Cirillo, D. M. (2019).
Acquisition of cross-resistance to Bedaquiline and Clofazimine following treatment for Tuberculosis in
Pakistan. Antimicrobial Agents and Chemotherapy, (July). https://doi.org/10.1128/AAC.00915-19

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