Barriers and Facilitators to Adherence to Treatment

among Drug Resistant Tuberculosis Patients

in Georgia

Study Report

January, 2017

i
Acknowledgments
Curatio International Foundation would like to acknowledge financial support from the
TDR/WHO small grants scheme, which made it possible to conduct this study.
Curatio International Foundation expresses gratitude towards the National Center of
Tuberculosis and Lung Diseases for supporting the field work implementation of the study.
The research team would also like to express gratitude to the respondents who devoted
their time to the study.
The study report was prepared by Lela Sulaberidze and Ivdity Chikovani under the
supervision of George Gotsadze. The views expressed in the publication are those of the
authors and do not necessarily reflect the views of TDR/WHO.

i
Table of Content
ACKNOWLEDGMENTS I

INTRODUCTION 1
THE GLOBAL THREAT 1
GLOBAL STRATEGIES FOR THE FIGHT AGAINST TB EPIDEMICS 1
DESCRIPTION OF THE TB RELATED SITUATION IN GEORGIA 1
EPIDEMIOLOGICAL REVIEW 3
PROBLEM STATEMENT 5

METHODOLOGY 6
PURPOSE OF THE STUDY 6
DESCRIPTION OF THE STUDY POPULATION 6
METHODS 7
SAMPLING 8
DATA ANALYSIS 8
STUDY CONCEPTUAL FRAMEWORK 9
ETHICAL PRINCIPLES 10

RESULTS 11
STRUCTURAL FACTORS 11
MONETARY INCENTIVES FOR PATIENTS 12
SOCIAL FACTORS 13
SUPPORT FROM FAMILY AND FRIENDS 13
PEER INFLUENCE 14
STIGMA 14
PERSONAL FACTORS 15
AWARENESS 15
MOTIVATION 15
HEALTH SYSTEM FACTORS 16
FREE TREATMENT 16
PROGRAM MANAGEMENT 16
THE DECISION MAKING PROCESS 17
MEDICAL PERSONNEL 17
PERSONNELS FINANCIAL MOTIVATION 18
GEOGRAPHIC DISTRIBUTION OF MEDICAL INSTITUTIONS 19
MEDICAL FACILITY INFRASTRUCTURE 20

ii
DIFFICULTIES OF THE DOT REGIMEN 21
SIDE EFFECTS AND SYSTEMIC MANAGEMENT PROBLEMS 21
SERVICE PROVISION RISKS 22

DISCUSSION 23
SOCIAL AND STRUCTURAL FACTORS 23
PERSONAL FACTORS 24
HEALTH SYSTEM FACTORS 24

RECOMMENDATIONS 26

REFERENCES 28

iii
Introduction

The Global Threat

Tuberculosis (TB) remains a global challenge to public health throughout the world. Millions
of people fall ill with TB every year. According to the World Health Organization (WHO), in
2015, 10.4 people fell ill with TB, of whom 1.8 million died. TB has been a leading cause of
death among infectious diseases.1 In 2015 TB death rates exceeded HIV/AIDS death rates.
People of all ages can be infected with TB. In the age structure of the diseased, TB cases
prevail in the economically active segment of the adult population (aged 15-44). Therefore,
the disease burden is important in terms of its impact on a countrys economy. It has been
estimated that TB currently causes a loss of around 12 trillion US dollars to the global
economy, and it is expected that this loss will reach 16.7 trillion dollars by 2050 if the
current spread of the disease is maintained.2

Global Strategies for the Fight against TB Epidemics

From 2000 to 2015, global and national efforts to reduce the disease burden were set by the
Millennium Development Goals (MDGs); in particular, target 6c of MDGs focused on the
reduction of new TB cases. The Stop TB partnership, which was established in 2001,
introduced new targets for countries to halve the TB prevalence and mortality rates
registered in 1990 by 2015. According to the Global TB Report 2015, these targets were
achieved: mortality rates in 2015 dropped by 47% compared to 1990 (the biggest decrease
was registered in the period following the year 2000), while the TB prevalence rate fell by
42% between 1990 and 2015.3 In 2015, following the end of a 15-year cycle of the
implementation, the MDGs were replaced by new Sustainable Development Goals (SDGs),
which are due to be implemented by 2030. The Stop TB strategy was also replaced by the
End TB strategy, which covers the period 2016-2035.

Description of the TB Related Situation in Georgia

The fighting against TB is one of the most important objectives of the health care system of
Georgia. As a result, reducing the spread of the infection among people is one of the goals
of the National TB Program.4
According to official statistics provided by the National Center of Disease Control and Public
Health (NCDCPH), the TB incidence in Georgia reached 74.7 per 100,000 population in 2015.
Even though Georgia has seen a decreasing trend in TB incidence over the past several
years, the Drug Resistant TB (DR-TB) prevalence rate is still high, accounting for 11.6% and
38.8% of new and of previously treated TB cases in 2015, respectively 5 (Figure 3).

1
The rate of loss to follow-up among patients with DR-TB is high (33%), which creates a risk
of spreading drug resistant forms of TB (Figure 5).
Patients have access to free TB diagnostic and treatment services as part of the National TB
Program. The program has been implemented by the National Center for Tuberculosis and
Lung Diseases (NCTLD). In 2012, the NCDCPH was assigned to carry out surveillance of TB as
part of the National TB Program, to trace the contacts of TB patients and to work with
patients who are lost to follow-up. Sputum microscopy and the transportation mechanism
from TB treatment facilities to TB laboratories are organized by the NCDCPH laboratory
network.6 Second-line TB drugs are purchased with the financial support of donors,
specifically the Global Fund, the governments of the US and of France. The TB control
strategy based on DOTs principles was partially implemented in 1995 in Georgia and
achieved full country coverage in 1999.
Georgia has achieved significant results through the introduction of internationally
recognized strategies and practices. For example, the country has met MDG 6c and the Stop
TB Partnership 2015 targets through reducing the prevalence and mortality rates of TB by
50% compared to 1990.6
As part of the national TB program, services are provided by public and private healthcare
providers. Currently state owned centers have been maintained, mostly in Tbilisi. In 2011, as
a result of one of the reforms of the healthcare system the privatization of medical
facilities the vertical system of management was changed and an integrated model of TB
service provision was introduced instead. As part of the reform, private providers in the
regions were required to carry out TB services.7 Private providers are due to perform this
obligation until 2018, in line with the requirements of the reform.
As part of the reform, TB services were integrated into primary healthcare facilities to
improve geographical access to DOT services for the population living in rural areas. Since
2012, patients have been taking drugs under the direct supervision of nurses working at
primary healthcare facilities as well.7
The national TB program provides patients with full coverage for diagnostic and treatment
service costs. A primary care physician refers people suspected of having TB to TB facilities,
where they have free access to TB services.

2
Epidemiological Review
The number of TB cases has been decreased in Georgia in the past decade.
Figure 1. TB cases per 100,000 population, 2005-2015 yy.

160
TB cases per 100,000 population

140

120

100

80

60

40
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

All cases New cases

Source: Statistical Yearbook Health Care in Georgia 2015, NCDC

Georgia no longer belongs to the group of countries with a high burden of DR TB. As of
2016, however, the DR-TB prevalence rate is still high among new and previously treated TB
cases.
Figure 2. DR-TB prevalence in Georgia, 2005-2015 yy.

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

New cases Previously treated cases

Source: Statistical Yearbook Health Care in Georgia 2015, NCDC

3
DR-TB prevalence is higher in Georgia than in countries in Central and Eastern Europe.
Figure 3. DR-TB prevalence among new and previously treated cases (%), 2015

80

70

60

50

40
%

30

20

10

0
Romania Czech Bulgaria * Latvia * Georgia * Armenia * Lithuania * Estonia * Belarus
Republic

New cases Previously treated cases

Source: Global Tuberculosis Report, 2016, WHO

Statistical Yearbook Health Care in Georgia 2015, NCDC

Regarding treatment outcomes, it should be noted that the treatment success rate among
DR-TB patients is not satisfactory enough in the country.
Figure 4. Treatment Success rate (%) among DR-TB patients, 2015

80

70

60

50
41
40
%

30

20

10

0
Estonia * Latvia * Belarus Bulgaria * Armenia * Georgia * Romania Lithuania *

Source: Global Tuberculosis Report, 2016, WHO

4
The trend over the past several years shows that one-third of DR-TB patients stopped
treatment.
Figure 5. M/XDR-TB treatment outcome (%) 2011-2013yy cohorts

2013 41 33 9 6 11

2012 46 32 6 3 13

2011 50 34 6 3 7

Treatment success Lost to follow-up Died Treatment failed Not evaluated

Source: National Center for Tuberculosis and Lung Diseases, 2015

Problem statement
High rates of loss to follow-up among DR-TB patients increases both the risk of spreading
the disease widely and disease-related health care costs.8 A retrospective cohort study
conducted in Georgia in 2013 revealed a high proportion (29%) of loss to follow-up among
TB patients, with over 40% of these cases occurring during the first eight months of
treatment initiation.9 While the study documented individual related risk-factors, including
gender (male sex), illicit drug use, tobacco smoking, a history of previous anti-TB treatment
and pulmonary TB, it did not identify programmatic factors that led to poor TB treatment
outcomes. Scientific literature describes the key barriers to adherence to treatment that
have been identified for years as a result of qualitative studies conducted on the issues. The
main factors that enhance or hinder adherence to treatment are as follows: the
organizational structure of TB treatment and surveillance services; regulations; the financial
burden; the knowledge, attitudes and practices towards TB treatment; personal qualities
(behavioral traits); side-effects caused by the treatment; individual interpretation of
illness and wellness; family, and community support.10,11,12
This document summarizes the factors affecting adherence to DR-TB treatment in Georgia
that were studied as part of our research and proposes recommendations to overcome
existing weaknesses.

5
Methodology

Purpose of the Study

The research aims to study in detail the factors related to loss to follow-up from the
perspective of patients, providers and the health system, and to develop relevant
recommendations in an effort to improve patient adherence to TB treatment.
The study aims to answer two important questions: 1) What factors enhance or hinder the
process of adherence to treatment among DR-TB patients? and 2) How can the health care
system be strengthened to improve treatment outcomes?
The research evidence will help policy makers to design and implement effective strategies
to improve TB treatment outcomes throughout the country. Considering that many former
Soviet Union countries face similar challenges in terms of TB epidemic control and
management, the evidence identified for Georgia could be relevant to other countries in this
region.

Description of the Study Population

The population groups participating in the research were as follows:
TB patients. Given the purpose of this research, the largest target group consists of
TB Program beneficiaries. During the study implementation, patients were divided
into the following subgroups:
DR-TB patients who interrupted treatment (lost to follow-up patients). For the
purpose of this research, the term Treatment Default has the meaning defined
by the World Health Organization as treatment interruption when the patient
does not visit a medical institution to receive appropriate medical treatment for
at least two consecutive months.
DR-TB patients who are currently undergoing treatment but do not accurately
comply with the regime i.e. so called recalcitrant patients.
DR-TB patients who successfully completed treatment.
The target group consisted of persons aged over 18 who speak Georgian.

Key Informants. This group consists of the people who manage the TB program in
Georgia, policy makers, healthcare managers and other specialists working at the
Ministry of Labor, Health and Social Affairs of Georgia, the National Center of
Disease Control and Public Health, the National Center of Tuberculosis and Lung
Diseases, as well as representatives of NGOs who have important information about
the TB Program implementation process in Georgia.

6
 Service Providers. This group consists of doctors (phtisiatrists and epidemiologists)
and nurses (DOT nurses, primary healthcare nurses involved in DOT services at rural
ambulatory hospitals), who provide TB diagnostic and treatment services to patients.

Methods
The study was implemented using a qualitative research approach. Data were generated
from in-depth interviews, semi-structured interviews and focus group discussions (FGDs).
In-depth interviews were conducted with the specialists in this field in order to
collect information about the problems or systemic shortfalls that occurred during
the TB Program implementation in Georgia. In total, 6 interviews of this type took
place;
Semi-structured interviews were conducted with patients; and
FGDs were conducted with service providers. Meetings were organized with
phthisiatrists, epidemiologists and nurses who provide DOT services at special TB
departments, primary healthcare centers or any place convenient for patients (so
called visiting nurses).
The geographic area of the research included Tbilisi and the regions of Adjara and
Samegrelo Zemo Svaneti. The regions were selected based on a high incidence of
tuberculosis, the diversity of urban and rural areas with high and low density
settlements as well as geographic diversity (plains and mountains), and differences in
healthcare service provision and transport infrastructure.

The distribution of the FGDs across the study locations is shown in the Table 1 below:
Table 1. FGDs distribution accross the study locations

FGD Participants Tbilisi Samegrelo Adjara

Visiting nurses

DOT nurses

DOT nurses in the primary healthcare

facilities
Phtisiatrists

Epidemiologists

7
Sampling
We used different sampling approaches to recruit different types of respondents in the
study (please see Table 2 below):
In order to select specialists working in this sector, we used the target sampling method (the
respondents were selected based on the research teams knowledge and experience) and
Snowball sampling (when a participant gives information about persons who are very
knowledgeable about TB related issues). The targeted selection method was used to select
service providers.
A two-stage sampling process was applied to select patients. At the first stage, employees of
the National Center of Tuberculosis and Lung Diseases who worked on electronic data bases
and patient registration had to retrieve data based on patients geographic locations. For
the purpose of this research, every n-th patient was selected proportionally from Tbilisi. In
total 60 patients were selected. At the second stage, employees of the Adherence Unit of
the National Center of Tuberculosis and Lung Diseases (two people) called the selected
patients and offered them to participate in the study. The patients received information
about the purpose, objectives and type of the research. If a patient agreed to participate,
he/she received a telephone call from a researcher to agree the time and place of the
interview.
Table 2. Sampling methods used in the study

Respondent Category Sampling Method

Specialists Snowball Principle, target sampling

Service Providers Target sampling

Patients Random sampling

Data Analysis
The information received during the interviews and discussions was analyzed using the
qualitative data analysis software Nvivo. At the beginning, a thematic tree for the NVivo
software was built in order to code the data and group the results.
The interviews were recorded on a Dictaphone in agreement with the respondents. Based
on the audio records, the researchers assistant prepared verbatim transcripts in which a
number was assigned to each respondent, without any personal identifiers.
In order to build a detailed coding tree, a group of researchers studied the interviews
organized in the transcript format. After the tree was built, the data analysis started. The
data coding and analysis process was supervised by the leading expert.

8
Study Conceptual Framework
For the conceptual framework of this research we used a model in which different factors
were clustered into groups of structural, personal, and social factors, as well as a group of
health system factors. The conceptual framework was based on the results of qualitative
research into tuberculosis treatment adherence, which is described in the systemic
overview of 44 publications.10
The structural group consists of the factors that are beyond a patients control and can
hinder adherence, despite a patients strong motivation.
Social factors influence personal factors and may improve adherence by increasing a
patients awareness level, changing his/her attitude to the disease and increasing
motivation. On the other hand, stigma and marginalization create adherence problems.
According to the conceptual framework, the factors influencing patients behavior can be
divided into structural and social factors on the one hand, and health system factors on the
other hand. Personal factors also influence health system factors, i.e. the personal and
system factors have mutual influence on each other.
Picture 1. Conceptual framework

9
Ethical Principles
The research was conducted in compliance with the World Medical Association's Helsinki
Declaration principles on medical research involving human subjects, which limits access to
information about the participants identity, identification data, place of work and other
personal information.
The research protocol and instruments were submitted to the NCDCPH National Bioethics
Committee. The protocol was also sent to the National Center of Tuberculosis and Lung
Diseases for approval by the Ethics Commission. On April 19, 2016 we received consent from
the National Bioethics Committee (Minutes N2016-022). The consent from the National
Center of Tuberculosis and Lung Diseases was received later.
The respondents were informed that when their answers were cited in the Research Report,
only the respondents category would be specified.
In order to comply with ethical principles, respondents were selected rather cautiously,
according to the above described procedure.
Face to face interviews were conducted in a private environment: a residential apartment or
nearby open area (a yard, garden or park).
Before interviews started, information about the study was once again provided to patients
by means of an information leaflet or telephone call. They were also informed that they
could call and ask questions about the study at any time. After this procedure and before
starting the interview, respondents signed an informed consent form to participate in the
study. If a patient refused to sign the form, a researcher signed it based on a patients oral
consent attained.
Audio records of interviews / focus group discussions were made in agreement with
respondents and focus group participants. If they were against audio records, the
researcher or his/her assistant wrote down respondents answers. In the case of focus
groups, the researchers assistant took notes of the focus group discussion results.
The audio records were stored in compliance with the organizations data management
policy, which implies limited access to the data (access rights were only given to the people
participating in the study) and destruction of the data six months after the end of the study.
The informed consent forms are stored in a safe place and will be destroyed 3 years after
the end of the study.

10
Results
Before presenting the qualitative research results, we will briefly present the social and
demographic characteristics of the respondents. 70% of the respondents are male. The
average age is 42 (The median age - 39). Other characteristics of the patients are presented
in the Table 3 below:
Table 3. Socio-demographic characteristics of the patients

Respondent Marital Status: Social Status: Employement Conviction Record:

Category Married Vulnerable status:Employed Former Prisoner

Successfully completed
65% 5% 80% 10%
treatment (N=20)

Lost to follow-up
45% 30% 40% 20%
patients (N=20)

Recalcitrant patients
60% 30% 27% 20%
(N=20)

As expected, the study revealed different positive and negative factors influencing
adherence to TB treatment.
The study results are presented according to the conceptual framework.

Structural Factors
Some social and economic factors prevent patients from completing the treatment. Despite
the fact that the treatment is provided to patients free of charge under the national TB
program, some patients cannot find time for it because of their employment or social
conditions (if a patient has to choose between employment and treatment, preference is
given to employment).

...I stopped the treatment because I am the only man in the family. I have two
sisters who are single and I cannot leave my family members hungry. I had to
work but it is very difficult to combine work and treatment at the same time...
A lost to follow-up patient
The working hours of employed patients do not allow them to comply with the treatment
regime. Besides, some patients do not tell their employers about their disease because of
stigma or fear of losing their jobs. Therefore, it is difficult for such patients to combine the
work and treatment regimes:

...I work at a distribution company where nobody knows about my disease. If they
find out, I will lose my job. I distribute bakery products so they will fire me
immediately. On Saturday, I do not receive the medicine because it can only be taken
at the Center before 12 oclock in the afternoon, but I finish work at 2. My working
hours start at 5 oclock in the morning... A recalcitrant patient

11
On the other hand, communication with colleagues and going to work helps patients to
overcome negative side effects of treatment and/or bad reactions to the treament. Those
patients who successfully completed the treatment stated that during work they paid less
attention to the sensations caused by the pharmaceuticals, which helped them to cope with
such factors.

...I have ideal colleagues. When they saw that I felt week and went out for
some rest, they did not make a problem out of this. I continued working and
did not sit at home all the time, which turned out to be a good decision.
Because when I was sitting idly and paying attention to the sickness, it lasted
longer...

A patient who has successfully completed treatment

Due to financial problems, patients with a low social status face difficulties in terms of taking
additional tests and purchasing medications for managing side effects (the side effect
problems are discussed in detail below, in the section dedicated to the healthcare).

...I paid less than GEL 10 for a visit to a cardiologist but the doctor prescribed
medicines for GEL 40. These were medicines for one week i.e. it would cost me
GEL 160 per month. I was prescribed a two-month treatment course. It is
difficult to by pharmaceuticals because I am the only employed member in a
family with two children...

A recalcitrant patient

Monetary Incentives for Patients

The incentive system works well among patients, especially in case of patients with low
economic status, for whom it provides a certain source of income. In some cases, a
monetary voucher works as an incentive.

Of course side effects mean additional expenses because you have to buy
additional medications. Nevertheless, this voucher creates additional
motivation because some people have no money at all and this helps

A patient who has successfully completed treatment

Besides the monetary voucher, patients also receive a voucher that covers their transport
costs. The amounts covered by the transport voucher equals the costs of coming from the
patients home to the DOT center by public transport. This voucher is given only to patients
with resistant tuberculosis.

12
Social Factors

Support from Family and Friends

According to patients, support from family members and society is very important during
the treatment. Conversations with family members help to overcome such problems as
loneliness, irritation and laziness to visit the center. The positive influence of support from
family members and society was mentioned by those patients who successfully completed
the treatment. None of them lived alone and all of them stressed the importance of support
from family members and friends:

...Support from family members is very important. You feel that you are not
alone. Sometimes I was too lazy to go to the DOT Center but my wife insisted
and forced me

A patient who successfully completed the treatment

...During the last period he became more nervous and irritated than before.
Although we behaved as if nothing was going on - as if the disease was not a
difficult one and could be easily cured. A correct approach to patients is very
important. An individual approach to each person is necessary. For example, if
I had not forced my husband to receive medicines, I do not know where we
would be now

A recalcitrant patients wife

Lack of attention from family and friends negatively affects adherence to treatment. When a
family member is actively involved in the treatment process and supervises the patients
visits, the patient has a more responsible attitude towards himself and the family:

...Because of my job I often had to go on business trips. I could not control

whether or not she went to receive medication

A lost to follow-up patients wife

When I returned home, problems started in my family. My wife caught the

TB infection from me. This became one of the reasons for our divorce. As a
result, I had to bring up three children alone. In autumn, one of the children
had to be taken to school but I did not feel well because of the side effects of
the medicines. I was unable to pay attention to the child. Following my return
from Abastumani, I had to take medicines for one year and four months in
total for 18 months, but I could not complete the treatment...

A lost to follow-up patient

13
Peer Influence
Decisions made by the majority of patients are greatly influenced by experiences shared by
other patients. According to respondents, the exchange of information about difficulties
overcome by other patients has a positive impact on adherence to treatment. The majority
of patients said that their decision to continue receiving medicine was a result of the
negative consequences of abandoning treatment, which they saw among other patients.
The positive influence of stories about successful treatment and coping with side effects
were mentioned with the same frequency.

I did not want to miss a day after I saw the condition of patients who
cheated and threw the drugs away

A lost to follow-up patient

For example, I sought patients who had completed treatment wondering

how they felt and how much time had passed since their treatment

A patient who successfully completed the treatment

Peers influence turned out to be negative when patients shared information on how to
avoid receiving some medicines and different methods of deceiving medical personnel.

Stigma
Due to stigma, patients conceal information about their illness and avoid communication
with people since they are afraid that the attitude toward them will change. Stigma was
mentioned by recalcitrant and defaulting patients as well as by those who successfully
completed the TB treatment. That said, only 15% of patients mentioned this issue and it has
never been named as the main reason for abandoning treatment.

...Since our region is small, people look differently at those who have
tuberculosis. This is why many of them, even family and friends, do not know
about our participation in the program...

A recalcitrant patients spouse

...During that period I often stayed at home and avoided contacts with many
people. Someone might suspect something, so I preferred to stay at home...

A patient who successfully completed the treatment

Specialists working in the sector emphasize the existence of stigma among medical
personnel. In a very few cases, patients also mentioned this.

14
Personal Factors

Awareness
According to phtisiatrists, they regularly inform patients in detail about the disease, its
process, special characteristics of the treatment regime and its possible side effects. Almost
all patients confirmed that they received detailed information about tuberculosis from
medical personnel. Despite this, an information deficit was revealed in case of defaulting
and recalcitrant patients. One fourth of these patients stated that they missed visits to the
DOT center or stopped treatment altogether because tuberculosis symptoms disappeared
or they felt much better. There were also some cases when patients abandoned the
treatment and then resumed it after the deterioration of their heath condition.

...During the first two months I visited the center regularly, received the
medicine every day and got better. After two months I stopped the treatment
because I was fine... A lost to follow-up patient

...I stopped the treatment a year ago and have not visited the TB hospital to
receive medicine ever since. Physically I was feeling well so I decided that
medicine was no longer needed...

A lost to follow-up patient

In some cases, patients expressed skeptical attitudes towards the new treatment scheme,
based on the belief that the new pharmaceuticals were experimental.

Motivation
Patients who had successfully completed TB treatment stated that one of their main sources
of motivation was the need to take care of family members, in addition to their own health.
These patients had a correct understanding of the seriousness of the disease and related
risks, so they tried to complete the treatment in order to avoid creating problems for their
family members and friends.

...I do not want to infect someone with tuberculosis. I could not allow a
situation when any of my family members and friends would have to go
through the same suffering as I did. And of course I wanted to recover...

A patient who has successfully completed treatment

... My motivating factors were my child and husband. I did not want to do
any harm A patient who has successfully completed treatment

15
Health System Factors
The health system factors were divided into two groups poor health system factors and
clinical factors. Health system factors include service organization and management issues
that influence adherence to TB treatment, while clinical factors are related to practical
medical activities.

Free Treatment
Patients spoke positively about the existence of the National TB Program in Georgia. The
opportunity to receive treatment free of charge was viewed as a huge benefit provided to
the population by the state. Many people stressed the high cost of the pharmaceuticals
which they received free of charge within this program.
I believe this is a rather expensive treatment, probably even one hundred
out of thousand patients would not be able to receive treatment, if patients
covered the treatment costs. This is a great support and everyone should take
advantage of this opportunity by all means

A patient who has successfully completed the treatment

Program Management
Besides free medical services and pharmaceuticals, all respondents spoke positively about
the opportunity to receive medicines continuously at DOT centers, which shows that the
program is working properly.
As for the management of the National TB Program, specialists and service providers
working in this area gave positive assessments to the appropriate laboratory network,
uninterrupted supply of pharmaceuticals, good program monitoring system and Doctors
Council.
Providers emphasized the positive steps made in the provision and management of TB
services. The majority of phtisiatrists spoke about a properly running laboratory system,
namely the opportunity to make tests timely and safely, the introduction of a new method
of lab diagnostics, the well organized transportation system and the implementation of the
Cold Chain principles. In addition, they also stressed the existence of a system that ensured
a continuous supply of medications and an opportunity to work without interruptions.
Service providers spoke about the benefits of the monitoring system, which did not allow
them to relax. They also expressed positive views about the approach focused on teaching,

16
mutual respect and healthy collegial relations between employees of the monitoring
division and service providers, which had a positive impact on their work:
Supervisors come from the center. The regional coordinator, who checks all
the forms, also arrives. They talk to a patient, his/her relatives and count
drugs. The system is organized very well; you have to do things even if you do
not want to. Moreover, the system focuses on teaching. Otherwise, we would
not have been here, everyone would have run away. The key point is that there
is a special approach, which is being further improved
Regional phthisiatrists' FGD

The Decision Making Process

Service providers expressed dissatisfaction with their limited involvement in the decision
making process. According to them, different changes were made in the program without
taking into account their views or even without their participation in the discussions. In
order to achieve progress, changes must be made taking into account specific practical
experience. Service providers gave several examples of such practice, namely the process of
development/improvement of reporting forms and improvement/simplification of sputum
transportation service.
...I do not understand why they invited us to the meeting if the problem had
been already resolved. Our views were not taken into account...

Regional phthisiatrists' FGD

As for the participation of patients in the decision making process, it must be noted that
patients did not even express such expectations.

Medical Personnel
The majority of patients stressed many times the positive role of medical personnel during
the long and difficult treatment period. Patients talked about attentive treatment they
received from doctors and nurses. According to them, nurses not only gave them the
prescribed medication but also provided moral support. If a patient was late, nurses
communicated with him/her frequently and in a number of cases tried to be flexible and
take into account a patients work schedule.
Attentive and compassionate medical personnel significantly influences patients behavior
and encourages them to complete treatment.
Physicians and nurses were positively disposed towards patients. They were
equally attentive to everyone and they motivated us to take drugs. They often
talked to us and supported us in everything. Nurses play a rather big role in
the treatment process; they provide moral support and additional
consultations A patient who has successfully completed the treatment

17
Target group discussions with specialists revealed a lack of young specialists working in this
field. As a result, the levels of acceptance and introduction of innovations are low. Low
salaries and health risks decrease the interest of young medical personnel in working in this
field.

Personnels Financial Motivation

Low Salaries

The research revealed a financial problem related to service providers namely, low
remuneration, which is below the average salary level. According to service providers, their
only stimulus is professional (intrinsic) motivation. In compliance with the Government
Resolution regulating the National TB Program, a phtisiatrists minimum monthly
remuneration is GEL 360, while DOT-nurses is GEL 280 (after taxes). As a rule, an average
monthly salary offered by employers equals a minimum salary. Indeed, a phtisiatrists salary
is considerably lower than a primary healthcare nurses salary, which definitely reduces
doctors motivation.

Salaries are rather low. It is rather bad that primary healthcare nurses have
a salary of GEL 450, while phtisiatrists receive GEL 360. This is a demotivating
factor for us Regional Phthisiatrists FGD

The same problem was identified in the case of epidemiologists. They talked about an
overloaded work volume and complained about inadequate financing of their efforts.

Epidemiologists work is not appreciated. We have to trace TB patients

contacts and visit families. We are at risk of infection, but nobody notices
that. It would be good if they changed the salaries or, if not, give us vacation
compensations...

Epidemiologists' FGD
The research also demonstrated that service providers do not have the full financial
support necessary to perform their obligations within the program. Doctors and nurses
have to cover the costs of communication with patients out of their own pockets, which is
not a small share of their monthly salary. At the same time, the examples above showed
that frequent communication positively influences the patients and stimulates them during
the treatment process.

When a patient does not come to take a medicine, we have to find out
where s/he is and why s/he has not come. We spend our salary to top up our
mobile phone accounts because we have to communicate with patients over
the phone all the time FGD with phthisiatrists and nurses

18
The Epidemiology Department is responsible for working with defaulting patients within the
framework of the National TB Program. However, our research demonstrated that the
system of finding lost to follow-up patients is not effective. In order to contact patients,
epidemiologists mostly use phone calls because transport costs are not covered.

... It would be good if I could make repeated calls to convince them; if there
were incentives; if we were given money for transportation, for example GEL
10. In this case we would manage to return lost to follow-up patients...

Epidemiologists FGD
Besides low remuneration, the Program currently does not have any incentive mechanisms
(financial or otherwise) for service providers, which usually has a negative impact on their
efficiency:

There is not even a small gift for us for a cured patient. We used to hold a
conference on World Tuberculosis Day in the past. Phtisiatrists from Georgia
used to meet each other, exchange information and we had dinner in the
evening. This was some kind of expression of gratitude, but there is nothing
like that nowadays

Regional phthisiatrists' FGD

Lost to follow-up patients stated that, before the treatment default, medical personnel very
actively contacted them when they missed visits and asked about the reasons why. After the
patient defaulted, medical personnel asked questions about the main reason but then all
communication stopped. Once a patient is designated lost to follow-up, medical personnel
are no longer obliged to contact them. Patients view this as a lack of attention from medical
personnel.

...Nobody is interested in us anymore. After my default, I did not get any calls
from the doctor during 7 months. Nobody has called and asked where I was
and why I stopped coming for the medicine. Only after 6-7 months, I was
called and asked to come for an interview (in order to participate in this
research)

A lost to follow-up patient

Geographic Distribution of Medical Institutions

The integration of services into the primary healthcare system increased geographic access
to services for rural population. This was mentioned by both patients and specialists.
At the same time, both patients and specialists talked about the existence of a geographic
barrier to service access for the Tbilisi population. The transportation of patients to DOT

19
centers is a problem because, at present, there are only four DOT centers in Tbilisi and their
locations are not evenly distributed.

... Even though we reimburse them for their travel expenses under the Global
Fund project, spending 3-4 hours every day getting to and from the clinic is a
barrier and problem for patients; moreover only MDR patients get
compensation...

A field specialist
The population living in regions has service access problems in terms of managing side
effects. They often have to go to Tbilisi to receive these services. As there is no adequate in-
patient hospital infrastructure in the regions, geographic access to such services is a
problem for regional population. Since regional in-patient hospital buildings are amortized
and the sanitary/hygiene conditions are poor, patients have to go to Tbilisi for such services.

Medical Facility Infrastructure

It is important to mention that DOT centers also have infrastructural problems. For example,
regional facilities do not have enough space to provide high quality ambulatory services.
Despite the fact that the condition of integrated facilities was improved, they often do not
meet international standards such as constant natural or artificial ventilation and ultraviolet
lights in doctors rooms.
Sanitary conditions at state-owned DOT centers are unsatisfactory since the buildings are
old and amortized.

Of course nurses maintained hygiene at the treatment facilities but the

building was rather old, walls were destroyed. It would be good to change or
repair the building. Worst of all, in X dispensary TB treatment unit is on the
first floor and people, including many children, live on the second floor
A lost to follow-up patient patient
Due to the inadequate space or poor sanitary conditions of ambulatory facilities, patients do
not have an opportunity to talk to each other and share experiences that would help them
to overcome difficulties. As noted above, sharing personal experiences has a positive impact
on the treatment process.

Conditions should be improved to encourage a patient to enter the office. I

used to go home right after taking the medicine. I could not and did not feel
like staying there and talking to others

A lost to follow-up patient

Unlike in Tbilisi hospitals, where conditions are satisfactory, infrastructural problems were
also revealed in regional in-patient hospitals.

20
Concerning clinical problems, difficulties were identified with regard to the DOT regime, pill
burden and side effects caused by the treatment.

Difficulties of the DOT Regimen

According to patients the treatment regime, which takes place under immediate
supervision, is problematic. This problem was mentioned equally by patients from rural and
urban areas. It is difficult for patients to visit medical facilities every day over a very long
period in order to take medicine. This causes the so called pill burden, which is difficult for
patients.
Patients included into the new treatment scheme have to visit a medical facility twice a day,
which is problematic even though they have transport vouchers. According to the new
scheme, patients have to take TB medicines in the form of infusions that can only be made
at in-patient hospitals.

It is not difficult to take medicines in the morning but when I have to come
here in the evening as well I start feeling sick. I have to come twice a day and I
drive here. Sometimes my father and my friends accompany me
A recalcitrant patient

Side Effects and Systemic Management Problems

The existence, frequency and management of side effects considerably influence adherence
to TB treatment. Many patients participating in the research talked about treatment related
physical and mental side effects. All lost to follow-up patients named side effects as one of
the main reasons for interrupting the treatment.
The management of side effects requires a knowledge of different organ systems by medical
personnel. Moreover, according to experts, specific knowledge and experience are
necessary to manage of side effects caused by TB medications.

Initially I used to recover more easily after taking drugs. They gave me
everything included in the program against vomiting, for liver, but
eventually I felt very bad and nothing helped me
A lost to follow-up patient
The National Program finances several medications for the management of side effects
suffered by patients with DR-TB. In addition, some tests and consultations with narrow
profile specialists are available for patients. The Tbilisi population has better access to such
services due to their availability at the National Center of Tuberculosis and Lung Diseases.
The Center has hired different specialists who play an important role in the management of
side effects. Moreover, Tbilisi patients are better informed and use universal healthcare

21
services to their benefit. In regions, patients either visit narrow profile doctors directly or
come to Tbilisi, which means additional expenses.

The management of side effects has been a problem because this involves
managing different systemic problems, such as the gastrointestinal tract. We
have faced this problem mostly in regions. We have not had this problem in
Tbilisi because the TB center has hired different specialists who are involved in
the management of side effects...

A field specialist

The program covers certain medications, for example, hepatoprotectors,

but side effects are managed weakly compared to TB treatment. The level of
treatment provided in Georgia is actually the same as in leading countries in
the world, but this does not apply to the management of side effects and
other remaining services. All those who travelled to France noted that the
situation was better there in this respect

A field specialist
The majority of patients talked about problems like nervousness, irritability, sleeplessness,
depression etc., which require the assistance of a psychologist/psychiatrist. Doctors and
other specialists working in this field also stressed the need for psychological assistance.

...Patients need psychological support. Sometimes she is so exhausted that

she does not want to take a medicine any more
A spouse of a recalcitrant patient

Some of them become rather reserved and find it harder to deal with this
psychologically, such people need to be supported by a psychologist
A patient who has successfully completed the treatment

Service Provision Risks

The study revealed the existence of service continuity risks. Some problems that put at risk
the provision of service by private service providers were identified in the regulations. The
situation is exacerbated by a lack of motivation at the institutional and personal levels.
Namely, it has become evident that the heads of medical facilities show less interest in
implementing unprofitable activities such as TB services, and that service providers have low
incentives to improve performance indicators since there are no mechanisms linked to
results.

They have undertaken an obligation, which they have performed more or

less. However, the term for the performance of these obligations will end soon
and I am not sure what is going to happen

A field specialist

22
Discussion

Social and Structural Factors

Apart from the influence of the health system factors, patients adherence to treatment also
greatly depends on social and structural factors. The study made it evident that support
received from family and friends by patients who successfully completed the treatment
was one of the positive factors that contributed to their success. In case of employed
patients, a supportive work environment is equally important.
The fear of losing a job often forces patients to make a choice between medical treatment
and income needed for existence. According to the results of quantitative research
conducted in Georgia in 2013, which studied 167 cases of patients with DR-TB, risk factors
for treatment default were the fear of losing a job and a lack of social support. 13 Studies
conducted in other countries also identified employment as a barrier to treatment
adherence.10,14,15,16
Patients fear losing their jobs if their employers and colleagues learn about their illness.
Besides, the Labor Code is not flexible and does not protect patients from losing jobs when
intensive medical treatment becomes necessary. According to the Labor Code, the
maximum length of sick leave for temporary disability is 40 consecutive calendar days,
which is much less than the duration of the intensive phase of TB treatment (the first two
months after it starts).17
Financial Incentives and compensation for transport costs were found to have a positive
influence on treatment adherence. The transport voucher increases patients motivation to
complete treatment. Moreover, in the case of social poverty the voucher is an additional
source of income for patients and can also be used to finance the additional medications
and tests needed to overcome side effects. The positive influence of financial vouchers on
successful treatment results has also been identified in other countries. 18
The Influence of Peers and sharing of personal experience among patients influences
treatment adherence. Personal stories of other patients about overcoming the unpleasant
side effects of medicines are especially important for those who are new to the Program,
because the number of questions the patients have is considerably larger at the initial stage.
On the other hand, patients may teach each other different tricks to avoid taking medicines,
which endangers their achievement of desired outcomes. Therefore, communication
between peers must be organized to ensure that patients who have already completed
treatment focus on appropriate issues.19
Patients mentioned stigma as one of the social factors causing them to hide their illness.
Even so, stigma has never been named as the main reason for abandoning treatment. The
same findings came out of the quantitative research conducted in Georgia in 2013: stigma
did not influence patients decision to abandon treatment. 13 Nevertheless, as mentioned

23
above, in combination with the employment factor, stigma creates an unfavorable
environment for treatment adherence.

Personal Factors
The research showed that one fourth of recalcitrant and defaulting patients abandoned
treatment because they no longer had symptoms and believed that they were cured. This
became a reason for their irregular visits or abandoning treatment. Despite the fact that
medical personnel gave the required information to patients, this incorrect perception was
still a problem and may be caused by their education levels and poor attitude to the disease.
Scientific literature describes cases when improvements in a health condition becomes a
reason for treatment default.10,14,19 This means that patients understanding of the disease
must be improved through different methods, such as involving peers, educating family
members and medical personnels use of a better communication strategy in order to
ensure the dissemination of correct and timely messages.
Care for family members was named as the main motivator of patients who successfully
completed the treatment. This group had a correct understanding of the disease, which
increased their feeling of responsibility towards family members and their desire to protect
them from the same problems.

Health System Factors

Out of all the positive health system factors, almost all of the patients emphasized access to
free treatment within the National TB Program. Moreover, as a result of the proper
organization of the Program the patients do not have to wait to receive different services
and medications. TB field specialists and phtisiatrists also frequently emphasized providing
uninterrupted TB services to the patients. They also mentioned existence of a good program
monitoring system, which according to specialists is focused on teaching, and stimulates
health personnel to work better. Healthy collegial relations between the management team
and service providers stimulate better provision of medical services by service providers.
However, service providers are unhappy due to their limited participation in the decision
making process, because they have to implement these decisions and face any difficulties
that arise. Patients are not involved in the decision making process and do not expectat to
be. They do not realize how important their participation in the decision-making process is.
According to WHO recommendations, patients involvement plays a major role in the
patient-focused approach. This approach is based on the principle adopted in the Almaty
Declaration, according to which participation of people in the planning and implementation
of their health care is a human right.20
Attentive and positively disposed medical personnel are important for treatment
adherence. Medical personnel provide moral support to patients during the difficult and
lengthy treatment process. However, it must be mentioned that such an attitude is driven

24
exclusively by professional (intrinsic) motivation. The monthly remuneration of phtisiatrist
doctors is 2.5 times lower than the average nominal salary 1 and even lower than the salary
of a primary healthcare nurse. Moreover, doctors and DOT nurses spend some share of their
low salaries on communication with patients. Epidemiologists have been assigned the role
of collecting information about lost to follow-up patients and returning them to the
program. However, because of insufficient financing of operating expenses this role is not
properly fulfilled. At the same time, at present the system does not have any financial or
other incentive mechanisms to ensure the effective performance of medical personnel.
Many scientific papers stress the positive influence of result oriented financing mechanisms
on the improvement of service providers efficiency.21 It is also worth mentioning that the
low financial rewards and risks inherent in the work makes this field unattractive you young
medical staff, which will ultimately cause a personnel deficit problem.
The reform that integrated DOT services into the rural primary healthcare centers in 2012 to
address the problem of geographical accessibility to in-patient service in the regions had a
positive influence on treatment adherence, because the centers are located near patients
homes, which allows them to save transport time and money. A geographic access problem
currently exists in Tbilisi because there are only four DOT centers unevenly distributed in
city districts. This complicates treatment adherence among patients with DR-TB because
they have to spend several hours every day to get to the DOT centers.
Apart from the geographic access problem, there is also a problem related to the
infrastructure of medical facilities. Since the space of such facilities is small and/or the
sanitary conditions are unsatisfactory, patients are not willing or able to stay there, which
makes it impossible to share experiences with other patients, even though, as noted above,
experience sharing could positively influence TB treatment adherence. Infrastructural
problems can be addressed either by renovating old buildings (which are mainly located in
Tbilisi) or by integrating these services into the primary healthcare system (as was done in
regions). It is equally important to refine the requirements set for the institutions that
provide TB services. According to international TB management standards, service provider
facilities must have constant natural or artificial ventilation and ultraviolet lighting. 22 In
Georgia this is just a recommendation in the TB Management Guideline, 23 while according to
the Decree of the Government of Georgia on Adoption of Technical Regulations for High-risk
Medical Activities ultraviolet lighting is not required at all.24 Therefore, these regulations
must be brought in line with international standards.

1
The National Statistics Office of Georgia, average nominal monthly salary of hired employees, 2015

25
Regarding the clinical factors that influence TB treatment adherence, the research revealed
negative impact of difficulties related to the DOT regime. Studies carried out in other
countries also confirmed that the need to receive a large number of medicines for an
extended period is a negative factor. In order to improve TB treatment adherence, it is
necessary to develop and introduce new approaches to the DOT regime on a constant basis.
The same applies to side effects, which frequently become the reason for TB treatment
default.25 Research carried out in Georgia in 2013 also demonstrated that depression was
one of the main side effects causing default.13 Our study revealed that in order to manage
side effects, patients living in rural areas visit the National Center of Tuberculosis and Lung
Diseases in Tbilisi, which creates geographic and financial problems. The center hired
different specialists who are involved in the management of side effects. In order to
optimize costs it is possible to use TV Medicine in the regions and to manage patients side
effects remotely with a team of experienced specialists. The possibilities offered by TV
medicine are widely used in different countries.26 The study found out that the management
of side effects expressed in mental problems poses a specific problem due to system
fragmentation. One of the solutions would be the integration of mental healthcare services
into the primary healthcare system, which ould be also used for different medical needs.
The study also identified risks related to the continuous provision of services by service
providers in the future. This risk is caused by problems in the current regulations and by the
non-profitability of TB services.

Recommendations
The study made it clear that the structural, social, individual factors as well as systemic
factors in the healthcare sector are very closely interlinked and self-reinforcing. Therefore, a
multi-sector vision and approach needs to be applied to resolve the problems. The
recommendations given below are based on the study outcomes.
Legal/normative changes:
The Labor Code provision on temporary disability term must be reviewed to
take into account the need for TB treatment;
Regulations need to be developed/refined in order to ensure the continuity
of services rendered by private service providers;
The involvement of peer educators is necessary in the treatment process to share
their personal experiences with other patients using different strategies (formation
of groups, use of the social media etc.);

26
 Communication messages should be improved by emphasizing treatment adherence
barriers;
Increased participation of patients and service providers should be ensured in the
decision making process;
Increase the motivation of service providers by introducing result-based
remuneration mechanisms:
Providing incentives for medical personnel;
Providing incentives for heads and owners of medical facilities;
Increase the efficiency of tracing lost to follow-up patients through operational costs
reimbursement and epidemiologists financial motivation;
Fully integrate DOT centers into primary healthcare services in order to improve
geographic access for patients and open additional centers in Tbilisi in order to
reduce geographic barriers;
Introduce global innovations in TB treatment on a timely basis throughtout the
country with the aim of simplifying the DOT regimen;
Improve access to side effect management:
Use Telemedicine to reduce geographical and financial barriers, save
patients time and improve the clinical quality of services;
Integrate mental health services into primary healthcare;
Reimburse expenses on medications for socially vulnerable patients;
Motivate young professionals to enter the TB field by reducing the financial barrier
to postgraduate studies.

27
References

1
Global Tuberculosis Report 2016, WHO
2
The Paradigm Shift, 2016-2020. Global Plan to End TB. The Stop TB Partnership, 2015
3
Global Tuberculosis Report 2015, WHO
4
#308 Resolution of the Government of Georgia, On Approval of 2015 State Healthcare
Programs 2015, Annex #7 TB Management. The Government of Georgia, Tbilisi, 2015
5
Health Care. Statistical Yearbook 2015, NCDCPH
6
2013-2015 National TB Strategy and Action Plan, Tbilisi, 2013
7
#92 Resolution of the Government of Georgia. 2012 State Healthcare Programs, Georgia,
March 2012
8
Laurence Y.V., Griffiths U.K., Vassall A. Costs to Health Services and the Patient of Treating
Tuberculosis: A Systematic Literature Review. PharmacoEconomics. Doi: 33: 939-955. 2015
9
Kuchukhidze G., Kumar A.M.V., de Colombani P. et al. Risk factors associated with loss to
follow-up among multidrug-resistant tuberculosis patients in Georgia. Public Health Action.
Doi:http://dx.doi.org/10.5588/pha.14.0048. 2014
10
Munro S.A., Lewin S.A., Smith H.J., Engel M.E., Fretheim E., Volmink J. Patient Adherence
to tuberculosis treatment: A systematic review of qualitative research. Plos Medicine. 2007
11
Weiguo Xu, Wei Lu, Yang Zhou, Limei Zhu, Hongbing Shen, Jianming Wang. Adherence to
anti-tuberculosis treatment among pulmonary tuberculosis patients: a qualitative and
quantitative study. BMC Health Services Research. 2009
12
Mekdes K Gebremariam, Gunnar A Bjune, Jan C Frich. Barriers and facilitators of
adherence to TB treatment in patients on concomitant TB and HIV treatment: a qualitative
study. BMC Public Health. 2010
13
Study of Risk Factors Associated with Default from Treatment and Long Term Outcomes
of Default in Patients with Multidrug-Resistant Tuberculosis. Tuberculosis Prevention
Project in Georgia, USAID, 2013.
Podewils, Laura Jean et al. Patterns of Treatment Interruption among Patients with
14

Multidrug-Resistant TB (MDR TB) and Association with Interim and Final Treatment
Outcomes. Ed. John Z. Metcalfe. PLoS ONE 8.7 (2013): e70064. PMC. Web. 19 Jan. 2017.

28
 Kizito KW, Dunkley S, Kingori M, Reid T. Lost to follow up from tuberculosis treatment in
15

an urban informal settlement (Kibera), Nairobi, Kenya: what are the rates and
determinants? Trans R Soc Trop Med Hyg. 2011 Jan;105(1):52-7. doi:
10.1016/j.trstmh.2010.08.015.
16
Gust D.A., Mosimaneotsile B., Mathebula U., Chingapane B., Gaul Z., Pals S.L. et al. (2011)
Risk Factors for Non-Adherence and Loss to Follow-Up in a Three-Year Clinical Trial in
Botswana. PLoS ONE 6(4): e18435. doi:10.1371/journal.pone.0018435
17
Organic Law of Georgia the Labor Code of Georgia. Chapter IX, Article 36.
18
Torrens A.W., Rasella D., Boccia D., Maciel E.L., Nery J.S., Olson Z.D., Barreira D.C., Sanchez
M. Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective
cohort study in Brazil. Trans R Soc Trop Med Hyg. 2016
Horter, Shona et al. Where There Is Hope: A Qualitative Study Examining Patients
19

Adherence to Multi-Drug Resistant Tuberculosis Treatment in Karakalpakstan, Uzbekistan.

BMC Infectious Diseases 16 (2016): 362. PMC. Web. 19 Jan. 2017.
20
WHO, Empowering communities to END TB with the ENGAGE-TB approach.
Witter S., Fretheim A., Kessy F.L., Lindahl A.K. Paying for performance to improve the
21

delivery of health interventions in low- and middle-income countries (Review). Cochrane

Collaboration, 2012.
TB CARE I. International Standards for Tuberculosis Care, Edition 3. TB CARE I, The Hague,
22

2014
23
Management of Tuberculosis. National Guidelines on Clinical Practices. Tbilisi, 2015;
24
Decree N359 of the Government of Georgia on Adoption of Technical Regulations for
High-risk Medical Activities. Tbilisi, 2010
Nguyen Binh Hoa, Nguyen Viet Nhung, Pham Huyen Khanh, Nguyen Viet Hai, Bui Thi Tu
25

Quyen. Adverse events in the treatment of MDRTB patients within and outside the NTP in
Pham Ngoc Thach hospital, Ho Chi Minh City, Vietnam. BMC Research Notes, 2015
26
Parmvir Parmar, David Mackie, Sunil Varghese, Curtis Cooper. Use of Telemedicine
Technologies in the Management of Infectious Diseases: A Review. Clinical Infectious
Diseases. 2015

29