Tuberculosis in Nigeria

Executive summary

Tuberculosis (TB) is a major public health concern globally. The majority of cases are found in African countries. However, due to the prevalence of TB infection in these countries, the Sustainability Development Goals (SDGs) are said to be affected because of the increase in HIV cases; this has a great effect on TB prevalence particularly in Africa (World Health Organisation, 2006; Sustainable Development Goals, 2017). The recent studies that the World Health Organisation (WHO) (2006) had undertaken shows that the African population is around 836,669,000 in 2010, with a TB incidence of 2,299,000, with several deaths 250,000 and a prevalence rate of 2,800,000 (World Health organisation, 2006). Pulmonary Tuberculosis (PTB) is among the major public health concerns in Nigeria. It was declared a national emergency in 2006 because of the prevalence rate of PTB, after which the plan for TB control was developed (Federal Ministry of Health Nigeria, 2008).

Nevertheless, Nigeria is ranked 10th among the 22 countries with the highest TB prevalence rate in the world. It has an estimated 133 cases per 100,000 (prevalence rate) and around 93,050 cases registered. Regardless of the immense wealth of the country, Nigeria is facing a lot of challenges in its health care system. Among which is TB management and treatment which has been inflicted with many challenges such as poor infrastructures, ineffective data systems, and a lack of ownership of the TB programs (Daniel, 2006). However, in 2008 the success rate of TB exceeded 85% for the first year in TB history globally. Also, in 2007, 87% of patients were receiving TB treatment, the success rate was steady from 2006 – 2007 in all areas of WHOs presence. The TB control program that the federal ministry of health established had detected 83% of TB cases in Nigeria, and the majority of those cases have been cured through the Directly Observed Treatment, short-course (DOTS) therapy strategy (World Health Oraganisation, 2006). Records have shown that Nigeria has achieved 73% success rate of treatment in the 2004 cohort and an estimated 22% detection rate of cases with low-level threat, compared to a global figure of 37% in the same year (Daniel, 2006).

The Nigerian health care system is following the national health policy that was developed in 1998 which was recently revised in 2004. The goal of this framework is to assist Nigerians in attaining socially and economically productive lives with primary care as a foundation (Federal Ministry of Health Nigeria, 2008). Additionally, the health care system is run through 20,000 public and 30,000 private health care services across the country. This shows that more than 50% of the Nigerian health care system are run by the private sectors. Furthermore, the majority of the funding of TB treatment comes from international bodies, there are a lot of problems regarding the funding of TB treatment in Nigeria. There is a need for the Nigerian government to take logical efforts toward increasing the degree of funding for TB treatment at all levels (Federal Ministry of Health Nigeria, 2008).

The government needs to engage the communities, by teaching and training them on how they can take care of their health, and showing them the protective measures they can take in protecting themselves and their children from contacting TB or any other kind of disease (Akingbade, 2016). Also, the government should encourage the community health volunteers and community workers in seeing that they carry out their health activities effectively (Akingbade, 2016). In addition, some of the money the government spends on the health care systems should also go to the community health care organizations (Akingbade, 2016). This money can be used in paying the hospital bills of those that cannot afford to pay for their treatment especially those that live-in villages. Recently, the Nigerian health care system has been facing a lot of challenges due to the crisis (the Boko haram crisis) that took place in the northern part of the country (Yusuf, 2015). The Nigerian health care system can be improved if the violence and corruption stopped (Yusuf, 2015). Nevertheless, with all the problems facing Nigeria, TB prevalence and incidence has reduced significantly. It have reached a point where only a few cities in the countries are still facing slight TB problems with a small number of deaths among those suffering from the disease. These is due to the availability of drugs and advanced laboratories provided by the WHO and DOTS (Akingbade, 2016).

Introduction

According to WHO (2013), TB is a prolonged infectious illness which is caused by bacteria generally known as mycobacterium; it affects almost every organ in the body, but it is associated with the lungs according to 80% of its cases. The TB that is responsible for the infection of the lungs is called Pulmonary Tuberculosis (PTB) while the one that affects the rest of the organs is known as Extra-pulmonary Tuberculosis (EPTB) (Bello, 2010).

WHO (2013), holds the view that TB is among the major public health concerns globally, it mostly affects the low-income countries, about 80% of its cases are found there. According to a recent report by the WHO (2006), TB cases are declining with an estimated of 2% every year. However, new challenges are arising with an increase in drug-resistance TB and HIV co-infection. The determination of TB threat in low-income countries could have a great effect on meeting the Sustainable Development Goals (SDGs), particularly in Africa, due to increase in HIV cases which affects the prevalence rate of TB (Bone et al., 2000) (Sustainable Development Goals, 2017). The goal of the SDGs is to end the epidemic of TB and other communicable diseases by 2030 with the help of DOTS intervention. The health groups need to come together to assist in strengthen the fight against all airborne infections (World Health Organisation, 2006; Sustainable Development Goals, 2017). The authorisation is not just for the people with the disease but also the communities in general (World Health Oraganisation, 2006).

According to WHO (2006), African population is around 836,669,000 in 2010, with a TB incidence of 2,299,000, with several deaths 250,000 and a prevalence rate of 2,800,000. Nigeria is ranked 10th among the 22 countries with the highest TB problem in the world with an estimated 133 cases per 100,000 (prevalence rate), and more than 93,050 cases were registered in 2010 (Federal ministry of health Nigeria, 2011). One of the important thing in controlling TB and detecting cases is the treatment outcome monitoring (TOM), it is recognized as programmatic output (Federal Ministry of Health Nigeria, 2008).

WHO (2009) stated that the success rate at a global level exceeded to 85% for the first time in 2008, with 87% of patients receiving treatment in 2007. Furthermore, the treatment success rate did not change or improve between the years (2006 to 2007) in all WHO areas except for the European countries which were recorded as the lowest success rate globally at 67% (World Health Organisation, 2006).

The important of TOM had been recognized in Europe. A statement has been given to the WHO and the international union against TB and lungs disease in 1998 regarding the needs of standardizing and evaluation of the results of TB treatment globally (Daniel, 2006). The Nigerian TB control program have detected 84% of TB cases and has cured those cases through the DOTS therapy strategy (World Health Oraganisation, 2006). The Nigerian records have shown 73% success rate of treatment in the 2004 cohort, and detected 22% of cases that remains at low-level risk compared to global figure of 37% in the same year (World Health Organization , 2017).

History of tuberculosis

TB started to exist since the ancient time. It has inundated mankind throughout the human history. It has coursed a great epidemic before its receded, it’s started acting like any other infectious disease, due to the time factor this disease started to accept the challenge of clarification for the epidemic cycle (Daniel, 2006). TB have killed more people than any other microbial pathogen since the beginning of mankind.  Scientist have shown that the gene of mycobacterium has originated from millions of decades ago. It has separated into different regions; it’s started from endemic to pandemic due to the migration of people from one part of the world to another (Daniel, 2006). Mycobacterium was present in the East Africa as early as 2-3 million years ago and it was said to have infected hominids at that period. The recent strains of mycobacterium have said to originate from a common predecessor years ago (20,000-15,000 years) (Daniel, 2006). The circulating strains have fallen into the six major clades or lineage, which are said to have presented in the east of Africa. However, the global distribution varies, based on the known mutation rate of mycobacterium TB, analysis have shown that must of the diversity among these strains are originated decades ago (between 300 to 900 years ago) (Daniel, 2006).

However, West Africa was then known to be the inherited home of both tubercle and its human host. Thomas M. Daniel (2006), said there is a lack of evidence to indicate the recent existence of the disease in East Africa. Nevertheless, it was documented that TB existed in Egypt decades ago (about 5000 years ago). Thomas M. Daniel (2006), continue to say there is a distinctive irregularity of TB, as well as characteristic pott’s abnormalities, which have been found in the remains of Egyptian mummies. Scientist have amplified the DNA found in the tissues of the Egyptian mummies who are affected with the mycobacterium TB (Daniel, 2006). They found that TB is among the causes of skeletal diseases, the experiment that was conducted proofs that TB can also cause bone disease with time (Daniel, 2006).

Africans have been migrating to other countries for the past decades. One can assume that they took their diseases with them, including TB (Daniel, 2006). The same form of TB was also found in America after Egypt by the archaeologist. The earliest evidence of the pre-Columbian TB comes from the Andean region to America. There is an evidence that shows the occurrence of the disease throughout the hemisphere earlier to the arrival of the European researchers (Daniel, 2006). However, due to its popularity, the classical Greece called it phthisis (known as TB) (Daniel, 2006). Thomas M. Daniel (2006) said ‘’phthisis usually make its attacks mostly between the age of seventeen and thirty-four’’.

At the time Europe entered its middle ages, TB record becomes sparse. This does not mean the disease was gone. There is still evidence of its existence from a widespread site in and around Europe, during the millennium that followed the fall of Rome around the 5th century (Daniel, 2006).

As the disease started to regenerate, its start moving to the Northward from Italy to the northern Europe, new knowledge of the disease started to emerge. Thus, the invention of the stethoscope was part of the new knowledge and it was invented by Laennec (Daniel, 2006).  He was the first person to clearly explain the pathogenesis of TB and combined the idea of the disease, whether pulmonary or extra-pulmonary. Laennec not only expounded the theory on the pathology of TB but he also explained the physical signs of pulmonary disease. He also introduced the terms to be used in describing those findings, which are still use today (Daniel, 2006).

However, the medical practitioners and scientists are struggling to understand the etiology, even though they are surrounded by TB patients. Benjamin Marten suggested in 1790 during his studies that TB was indeed infectious in nature (Daniel, 2006).

Health care system in Nigeria

The Nigerian health system is based on the National health policy framework which was developed by the Federal Ministry of Health (FMH) in 1998 and was revised in 2004. The aim of the framework is to help Nigeria achieve a high health care level. Allowing Nigerians to attain economically and socially productive lives with primary health care as the foundation. The policy delivers a health system based on primary, secondary and tertiary organizations, supported, managed and financed by the Local Government Areas (LGAs), state and federal government at all levels. The LGAs are responsible for the primary level of health care, the state is responsible for the secondary level of care and providing technical management to the LGAs, while the federal government is responsible for the tertiary level of care as well as policy making and technical management of the states (Federal Ministry of Health Nigeria, 2008).

Furthermore, the health care services are provided through over 30,000 private and 20,000 public health care services spread across the country. All tertiary and most secondary health facilities have standard laboratories and the ability to provide basic laboratory services including microscopy for identification of TB. The private sectors, Non-governmental organizations (NGOs), faith-based organizations, community-based organizations and local communities, provide significant services at all level of health care including TB. The private sector provides more than 50% of healthcare services in the country (Federal Ministry of Health Nigeria, 2008).

Limitations and challenges of TB treatment in Nigeria

Regardless of the immense wealth in the country, TB management and treatment in Nigeria has been inflicted with many challenges. Some of these challenges are; poor patient’s referral system, poor infrastructures, lack of ineffective data systems, lack of efficient partnership between TB and HIV programs, poor supply management systems and poor procurement (Taofeek, et al., 2014). However, among the limitations the country is facing are; insufficient drugs and other consumables, ARV and CPT for TB/HIV co-infection, lack of ownership of TB control programs (response is majorly contributor driven), reduced coverage of IPT and dishonesty, these problems have eaten deep into the fabric of the country (Taofeek, et al., 2014). To tackle some of these problems there is a need for community needs assessment, in other to figure out the effective way to handle these problems and reduce the prevalence of TB in the country (Taofeek, et al., 2014).

Economical context of TB in Nigeria

The Figure 1 below shows a significant degree of under-funding of TB in Nigeria.

Source: Perspectives on community Tuberculosis Care in Nigeria by Akingbade O., 2016.

The majority of TB funding in Nigeria come from the international bodies, the domestic funding is low at an ebb. It was estimated that before Nigeria can meet the WHO goals by 2035 to reducing deaths of people from TB infection, from the current 246,000 to 24,400 (number of deaths by TB yearly). It has been estimated that Nigeria spends 81 billion naira (US$406 million) every year regarding TB treatments (Akingbade, 2016). This is around 68.2 billion Naira (US$341 million) above the current TB agenda, economical funding of around 13 billion Naira (US$65 million). These are higher than the WHO budget which was estimated to be around 27.8 billion naira (US$139 million), it is mainly due to additional cost for healthcare establishment and the MDT-TB treatment (Akingbade, 2016).

The figure also shows a lot of implication regarding the Nigerian economy toward TB treatment. Among the implication is a lack of efficient funding of the health care system in the country. However, it also shows that there is a need for the government to take a logical effort toward increasing the degree of TB funding at all levels. Recently, the government has taken logical steps toward fighting MDR-TB (Akingbade, 2016). Among the recent efforts that the government took is the procurer of quality assured second line drugs (SLDs) to provide treatment for 500 multi-drug resistant TB (MDR-TB) patients. The Nigerian government has spent over US$1.42 million on this drugs (Akingbade, 2016). The delivery of the drugs started toward the mid of June 2015.

In December 2013, new molecular diagnostics tools were introduced. Some of these tools are GeneXpert machines in 49 facilities in 30 states, and in Federal Capital Territory (FCT) (Akingbade, 2016). The availability of this equipment’s leads to the detection of more MDR-TB cases. The global fund contributed the sum of US$16 million, to be used in the treatment of the disease. These made the Nigerian government to have more effort in acquiring this treatment (Akingbade, 2016).

Problems of TB

PTB is among the major public health issues in Nigeria. In 2006 it was declared a national emergency, after which an emergency plan for controlling TB was established (Bello, 2010).

Despite the support of other organizations such as the introduction of DOTS and the Germen Leprosy Relief Association (GLRA), TB cases seem to increase in most parts of the communities in the country. It was observed that the number of referred patients that were admitted into the Eku hospital for confirmation of treatment and diagnosis have increased considerably (Ogaga, 2014). This shows the rapid increase and spreading of PTB infection among the members of the community (Ogaga, 2014).

However, monthly records have shown that 50 people come to the referral center with a history of a cough that lasted longer than three weeks for proper diagnosis (Ogaga, 2014). Thus, due to the monthly records, the anxiety of people seems to have risen.This poses a great challenge in the determination of prevalence and management outcomes.

Figure 2 below shows PTB records of patients in the Nigerian hospitals.

Source: Tuberculosis in Nigeria by Onorikpori Timothy Ogaga., 2014.

Solutions of TB

Nigeria took its first ever prevalence survey for TB in 2013. While waiting for the results, there was an indirect estimate that was been relied on over the years and it was found to be completely under-reported (Akingbade, 2016).Comparing it to the previously published estimates, the newly reported estimates are; 100% higher for prevalence, 200% higher for incidence and 400% higher for mortality (Akingbade, 2016). The survey illustrated a doubling in the estimated of the overall prevalence of TB and tripling estimated of incidence when comparing it to the previous estimates of WHO reports (Akingbade, 2016). The previous estimate of WHO report is shown in Figure 3 below.

Source: Perspectives on community Tuberculosis Care in Nigeria by Akingbade O., 2016.

Figure 3 shows that TB management has been overhauled. Nigeria has suffered far too long regarding the efforts used in controlling TB (Akingbade, 2016). Nigeria have faced quite a number of challenges in regards to the efforts used in controlling TB. One of the challenges that the government faced was convincing the people in the communities to come to TB test or any other disease test. The majority of people living in the Nigerian villages/communities do not like hospitals they depend on traditional medicine, these led to the high number of deaths in rural areas. The federal government needs to establish a community-based TB services across all the communities in the country to help with the diagnosis and treatment of TB (Akingbade, 2016).

The WHO have launched a strategy program called ‘’Global Stop TB Strategy’’, the intention of the program is to reduce the burden of TB across all African countries and in line with global burden of TB by 2015 (Nigeria Stop TB partnership, 2013). The general goal of the strategy is to dramatically decrease the global burden of TB by 2015 with the collaboration of the Stop TB Partnership and the Sustainable Development Goals targets (Nigeria Stop TB partnership, 2013; Sustainable Development Goals, 2017). Some of these Global Strategy are; pursue high-quality DOTS expansion and enhancement (e.g. political commitment with increased and sustained financing and an effective drug supply and management systems); empower people with TB in the communities (e.g. through Advocacy, communication, social mobilisation, community participation in TB care and patients charter for TB care); enable and promote research (e.g. research to develop new diagnostics drugs and vaccines and also through programme-based operational research) and lastly by engaging all care providers (e.g. through an international standards for TB care (ISTC) and Public-Public, and Public-Private Mix (PPM) approaches (Nigeria Stop TB partnership, 2013; Sustainable Development Unit , 2014).

Another method of treating TB is recognizing the magnitude of the disease and finding a way to reduce the burden of the TB (measured as prevalence, incidence, mortality and socio-economic impact), methods have been set within the global framework to treat TB cases. These are; Stop TB partnership, and Sustainability Development Goals (SDGs) (Nigeria Stop TB partnership, 2013; Sustainable Development Goals, 2017).

Figure 4: TB Control in MDGs

Source: Nigeria Stop TB Partnership Strategic Plan 2013-2015 by Nigeria Stop TB partnership, 2013.

The figure 4 above shows TB control in Millennium Development Goals (MDGs). This goal expired in 2015, but it purpose is to address the three public health diseases of global significance. The aim of the goal is to fight against Malaria, HIV/AIDS and other related diseases including TB (Nigeria Stop TB partnership, 2013). However, a new goal was established after the expiration of the MDGs. The SDGs was established to replace the MDGs, its serves the same purpose as the MDGs but few changes have been made comparing the table with figure 5 below (Nigeria Stop TB partnership, 2013; World Health Organization , 2017)

The red part of the table shows the Stop TB partnership which includes two additional targets. The first target was reducing prevalence and death rate by 50%; compared to their levels in 1990. The second target was eliminating TB as a public health problem; defined as the global incidence of active TB of less than one case per one million population per year (Nigeria Stop TB partnership, 2013; World Health Organization , 2017).

Figure 5: Sustainability Development Goals (health in the SDG era).

Source: Sustainability Development Goals by World Health Organization (2017)

SDGs have a specific target as shown in the figure 5 above. The aim of the goal was to fight TB and other major communicable diseases like HIV/AIDS and to measure the global performance of TB control. The incidence, prevalence, and death associated with TB have been reduced under the SDGs and DOTS operations (Nigeria Stop TB partnership, 2013; World Health Organization , 2017).

Community needs assessment

There is needs for community health assessment in Nigeria because most of the activities that happened, happen in the communities, outside the premises of formal health care facilities. The majority of the activities happen within households and the community-based structures (Akingbade, 2016). The method of working in collaboration with the and through communities to address the problems affecting the health of people living in the societies can be known as community engagement (Akingbade, 2016).

These kind of activities can be implemented by community health volunteers and the community workers regardless of their positions (either employed or supervised) and whether they are working with NGOs or the governmental organizations. However, with the help of the community workers and volunteers, TB detection and notification will increase which will help in the improvement of treatment outcomes (Akingbade, 2016).

The involvement of the communities in the delivery of the health services to people is not new. Communities have been engaging in the protection and support of their members when it comes to health. The conference that took place in Alma-anta in 1978 mentioned clearly, the efficiency of organized community involvement and ultimate self-reliance with people, relations, and communities assuming more concern on their own health (Akingbade, 2016).

Moreover, the method that have been used for quite a while to combat TB have not concentrated on the community involvement. For example, in Nigeria, Public-Private-Mix (PPM), advocacy Communication and Social Mobilisation (ACSM) are on the weak note (Akingbade, 2016).

The DOTS strategy cannot be used as a substitute for community TB care. On the other hand, it builds a positive experience in the communities by training the health workers and volunteers how to take care of patients or individuals in the societies/hospitals (Akingbade, 2016).

Sustainability and resilience of TB

The best way of achieving sustainability is through interventions. It will help in creation of resilience, sustainable, healthy places and people perspective. These can be done through educating the communities, which will help in the improvement of health in and around the communities (Public Health England, 2014). PHE (2014) also added that it is important to value and maintain our physical and social environment. These will yield in the strengthening our social environments and the communities, through the reduction of negative impacts (Sustainable Development Unit , 2014). On the other hand, it will have a positive effect on the reduction of physical, mental and social inequality (Fair Society, Health Live, 2010).The figure below shows a sustainable approach in interventions.

Figure 6: Sustainability approach

Source: Public Health England (2014).

According to the Federal Ministry of Health Nigeria (2014), the majority of people that are diagnosed with TB infection come from poor communities. This lead to high prevalence, mortality and incidence rate of TB in the country.  In response, to this high prevalence of TB in the communities, the WHO introduced an intervention called ‘’Stop TB strategy’’ (World Health Organisation, 2006). The aim of the intervention is to reduce the spread of TB through the application of multi-disciplinary methods. However, it will take a lot of time and effort for the communities to gain back their resilience (Sanchez, et al., 2006). To achieve this intervention, some changes must be made due to the community’s settings. The majority of the Nigerian communities consist of different people from different social, cultural and backgrounds living together in one community. These people come to live in these communities either for business or educational reasons. Thus, for these reasons, the application of most strategies is barely reached (Selgelid, 2007). Accordingly, there is a need for the authorities to find a strategic approach of handling the intervention to avoid any ethical problem, regarding the community settings (Harris, et al., 2004; Directly Observe Therapy for treating tuberculosis, 2007).

Lately, northern Nigeria is facing a range of health issues due to the problem of terrorism (Boko haram) in Barno state and its surrounding cities. The majority of people living in these cities are emigrating to nearby cities for safety and shelter (Yusuf, 2015). Some of these emigrates have diseases that they bring with them, among which is TB. The federal ministry of health, helped in screening out immigrants that are said to have a complex disease like HIV/AIDs and TB before they enter the communities (Taofeek, et al., 2014).

In order to maintain sustainability, the stakeholders, and private sector must give their supports to help the economy of the country, become more sustainable (Taofeek, et al., 2014). Good policies can help in the political and management support to ensure sustainability. These policies have to be based on principles that are appropriate for the state and its surrounding cities (World Health Organisation, 2006). The participation of the government and the private sectors is important in maintaining the sustainability of the intervention, due to funding. There is a need for awareness and understanding of health needs of the people living in the Nigerian communities, along with the understanding of the impact the emigrants have on their health (Taofeek, et al., 2014).

Ethical consideration

The majority of people that are suffering from TB in Nigeria are the underprivileged; these brings up the point of social inequalities in the country (Selgelid, 2007). A lot of people are becoming immune to the treatment due to the method used in delivering the medication. The health care workers are doing all they can to see that human right and justice is being upheld in the treatment of patients. They also treat patients equally in the hospitals even though corruption is highly prevalence in the country but not all the Nigerian hospital are corrupt, few hospitals are still following the health care system guidelines (Selgelid, 2007).

However, among the public health interventions that been carried out by the Stop TB strategy include isolation of TB patients in the hospital/communities, taking the approach of utilitarianism and non-maleficence into practice for the greater good of the communities and other patients in the hospitals. The health workers must respect the autonomy of patients and the rest of the communities (Selgelid, 2007). Nonetheless, TB has been ignored in bioethics, even though it kills as many people as AIDS (Selgelid, 2007).

Regarding the threat of DR-TB, the federal ministry of health has collaborated with the WHO and other health organizations to find a way of handling the transmission of the disease. They created a programmatic organization for the treatment of DR-TB in the country. The goal of the organization is to effectively control the spreading of the disease (Taofeek, et al., 2014). The programs are run under ethics and policy guidelines of the Nigerian healthcare system, to ensure that patients and the members of the communities are taking care up according to the ethical principle guidelines (Taofeek, et al., 2014). 

Reason behind the interventions

There are significant number of factors that aids the spread of TB, among these factors, are the social factors. Social factors play a vital role in the spread of TB and not a lot of emphasis is given to it in regards to interventions. According to Benjamin et al (2014), TB intervention is the most cost-effective in health care compared to HIV which is ten times the cost of TB treatment and it is needed for a lifetime. However, TB prevalence and sustainability treatment have increased by 40 – 80 percent (treatment rate) because of its cost-effectiveness (Taofeek, et al., 2014). TB is more infectious than HIV due to its method of spreading, TB is an airborne virus while HIV/AIDS is a sexually transmitted infection. According to Floyd et al (2006), DOTS is the desirable cost-effective intervention in decreasing the spread of TB. These is due to it decreasing long-lasting hospitalization and at the same time it is the best way of improving treatment percentage and in the reduction of DR-TB (World Health Organisation, 2002).

Since the implementation of DOTS, case detection has increased along with treatment which results in the reduction of prevalence and mortality (Balabanova, et al., 2006). The success of the DOTS intervention was observed in two countries with high incidence rates (Peru and China), the incidence rate of Peru has been declining by 6% yearly (Balabanova, et al., 2006). Also in China, the prevalence rate has reduced by 30% between 1990 and 2000, making DOTS a positive sustainable intervention (Balabanova, et al., 2006).

Volmink (2007) have shown the impact of DOTS intervention, and have proven that it is sustainable and effective. additionally, before the implementation of DOTS intervention, only 2% of cases were detected and treated, after the operation of DOTS the detection and treatment rate increase significantly (60% detection and treatment rate). According to United Nations MDGs (2011), over 5.7 million TB cases have been identified through the intervention (DOTS) in 2009. However, randomized controls trials have shown that there is no difference in results between the self-administered therapy and that of DOTS intervention (Volmink, 2007).

Since the operation DOTS intervention, it has proven its sustainability and effectiveness globally. The table below shows the overall outcome of patients with TB in Ogbomosho, Oyo state (south-western Nigeria). The second table shows the associating factors, with favorable treatment outcome.

Figure 7: overall outcome of patients with TB treatment and factors associated with favorable treatment outcome in Oyo state.

Source: Source: Treatment Outcome of Tuberculosis Patients Registered at DOTS Centre in Ogbomosho, South-western Nigeria: A 4-Year Retrospective Study by Sunday et al, (2014).

Additionally, DOTS is a highly efficient and effective way of treating TB. The success rate of TB treatment was 85.5% comparable to other results where DOTS strategy is currently operational, in some region of the world (Sunday, et al., 2014). Moreover, it was reported that the success rate of TB treatment in Benin republic has reached 78% and 82% among retreatment and new cases with 3% and 1% failure rate respectively (Sunday, et al., 2014).

In another study, it was reported that 66.5% cure rate was achieved in seven-month period after a short course of chemotherapy among Burundian and Rwandan migrants (Sunday, et al., 2014). Sunday et al (2014), continue to say that similar results were achieved with TB patients in Sudan (both Sudan and South Sudan), the treatment rate was 77.2% and 68.3% respectively. This result was achieved due to the full supervision of DOTS strategy in the treatment center.

Additionally, DOTS intervention is easy to implement globally. A lot of DOTS health workers have been going to villages and small communities in and around Nigeria to help the underprivileged people with TB and other diseases with free medications (Sunday, et al., 2014). Moreover, DOTS health team can carry out a routine assessment along with active case detection in Nigerian villages since the people there live a compatible life. This will make DOTS intervention more sustainable in and around the villages and communities in the country. Furthermore, according to Greifinger, Bick, and Goldenson (2007), they noted that to carry out DOTS intervention successfully, sanitized water and nutritionally balance foods have to be available under the treatment of TB. This is a major hurdle that is being faced along with violence, corruption, and underfunded health services in most African countries (Nigeria included).

According to Sunday et al (2014), communication is important and effective in the reduction of TB. It helps the doctors understand if the treatment is working before the results are out. The patients can express how they are feeling to the doctors and tell them if they are experiencing any side effects of the drugs either mentally or physically. Subsequently, extensive research has been conducted regarding health communication in developing countries, especially to HIV/AIDS, sexual health, and vaccination but limited among for TB control (Waisbord, 2007).

Recommendations

In other to re-position the TB management system in Nigeria. The following recommendations need to be put to action, in other to eliminate TB from Africa and other parts of the world in general.

  • The local, state and federal government need to give their support (financially) for the Community Tuberculosis Care (CTBC) to be fully operational.
  • Many Nigerians are not aware of Nigeria been one of the high-TB burdens in Africa and the world. The Community-Based Tuberculosis Care (CBTC) participant need to make people aware of how they can line up with the WHO’s post-2015 global strategy known as ‘the End of TB strategy’ (Nigeria Stop TB partnership, 2013).
  • The federal government needs to monitor and evaluate the TB management run by the private practitioners on a monthly or yearly basis.
  • There is a need for constant review training for community-based volunteers. The training should be role specific.
  • It is important for the government to monitor the CBTC service through timely review and evaluation is vital to the success of the programs.
  • The need for external funding in TB management cannot be over-emphasised. There is still need for the local and international bodies to support and fast-track the step of the operationalization of CBTC in the crannies and nook of the country (Akingbade, 2016).
  • The Nigerian government and the national TB control program should support and encourage the participation of all qualified private healthcare providers, under the public-private mix, directly observed treatment short-course strategy (PPM-DOTS), to guarantee the accessibility and availability of the services to patients (Akingbade, 2016).

Conclusion

In conclusion, TB is among the major health problems that is being faced globally (Reyes, 2007). Additionally, many obstacles are being faced worldwide in regard to ways of reducing the spread of the disease. In other to achieve DOTS strategy successfully, the government need to address the violence and corruption issues in the country, and DOTS implementation can be sustainable

However, there are a lot of ways to reduce TB prevalence and incidence, not just through DOTS but also through communication. These will help in the achievement of TB interventions and in the building of resilience in Nigeria and around the world. It is possible to achieve success in the reduction TB prevalence as evidence shows in India, Europe and all over the world through DOTS (Balabanova, et al., 2006). The establishment of TB intervention requires the coming together of all stakeholders, healthcare professions and the cooperation of the communities to work together to address the obstacles affecting the sustainability of DOTS. Evaluating the problems and solutions with health promotion can contribute in addressing person’s social barriers, which they faced due to lack of knowledge about TB (Waisbord, 2007).

The collaboration of local and federal ministry of health will help in addressing the structural systematic problems. Some of which are; the inadequate staff, insufficient resources and poor living conditions for those in local hospitals and rural areas, who are receiving treatment (World Health Organisation, 2006). The general participation of the organizations will not only help in addressing the obstacles that is being faced by individual-social aspect but also helps the stakeholders have a sense of ‘ownership’ in regards to the healthcare system in the country. These are important in the maintenance of a long-term sustainability in the fulfillment of effective interventions (Waisbord, 2007)

References

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