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Tuberculosis (TB) has been announced by the WHO a global emergency of this
Millennium. It is the leading cause of death among adults due to a single infectious agent.
The World Health Organization, for instance, estimates that the toll of tuberculosis mounts
annually to 3 million deaths and till 2020 the global burden of tuberculosis infections will
reach to more than one billion (WHO, 2002). Surprisingly more than 80% of the disease
burden comes from the poor resource countries where the rate of reemergence is faster
due to poor TB control and spending extremely inadequate. There is a common consensus
that the problem is due to scarce resources allocated to the control of TB but more crucial
is the problem how and where these resources are spent?. Global spending shows that only
10% of the resources are spent on diseases that cause 80% of global burden (WHO,2000).
Particularly extreme disparities and inequities have been noticed among countries which are
heavily confronted with increasing burden of infectious diseases. TB control in developing
countries is the recent and adequate example. Based on disease burden due to TB, 22
countries around the world, which are mostly developing countries are labeled as high
burden countries (HBCs). Unfortunately these high burden are less motivated in realizing
the epidemiological situation and accordingly do not converge their efforts to reduce the
burden of TB. Hence health system performance and quality of care decline, control
programs and interventions suffer, and the pool of infection rises and admittedly the risk
of harboring infection increases.
Another dilemma, that complicates the TB control in these high burden countries is the
lack of research on the subject. Mostly high burden countries have no capacities and
interest to explore the underlying causes. Very little is known about the health system
performance, epidemiological profile, community dynamics, and more importantly decision
making and prioritizing health problems. The need to generate more in-depth knowledge
and systematic vision about the existing interventions has become more than ever as the
socio-economic, political and demographic turmoil in these countries started exerting
pressure and put significant barriers in the health development and disease promotion. This
has been particularly true about the high burden country like Pakistan which is the focus of
this research undertaking. In 1999 total estimated new cases of TB were 269 000 equivalent
to 177 per 100 000 inhabitants and only 8 % of the total cases have access to DOTS
(supervised treatment strategy; short course) (WHO,2002). Annually more than 50000
deaths are associated with TB in Pakistan (MOH,2001). Countless queries arise about the
effectiveness of TB control measures that are in place since long time and operate across
the country. In spite inputs from various sources, program output and impact is not
enough to overcome or reduce the burden of TB in the country. The alarmingly emerging
state of TB infection coupled with resistant TB cases triggered the concept of evaluating
the TB control situation in an area where demographic, geographic and epidemiologic
factors coincide and contribute to the increasing burden of TB in Pakistan. Lack of
pertinent data and information on the operational, behavioral, community aspects of TB
control further energized motivations to explore the entirety of the subject in Pakistani
context. The study adopt a blend of approaches which are not only unique in its design but
unveil all crucial aspects, shortcomings and deficiencies of TB control interventions that
are considered integral for the eradication. The dissertation is intended primarily for
guidance in a country like Pakistan or elsewhere that is confronted with similar burden of
TB. The ultimate objective of the dissertation is to make sure that local, national and
institutional TB control programs are efficiently vigilant and put enough efforts to decrease
Tuberculosis Control in Pakistan
Chapter 1
=
the annual risk of infection, reduce morbidity and prevent mortality from TB. The
dissertation is also a summary of National TB Control Program·s (NTP) experiences,
achievements as well as in promoting and supporting national TB programmes. Pakistan
where the present research took place is one of the case studies with a process revealing
transitions occurred over a short period of time that has been documented separately,
including the personal contribution (Appendix Chronological Benchmarks: General and
Research Contributions). The literature review done in this regard provides extensive
background information to understand the context of TB control in HBCs.
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This study intends to examine the national control strategy in Pakistan and serves an
attempt to assess the programmatic, managerial aspects as well as the community
perspectives. It couples multiple methodological approaches to determine why the health
system has not been able to provide effective and sustainable strategy for preventing, early
detecting and treating tuberculosis and the degree of preparedness to topple TB. It also
explores why patient would delay seeking care or partially comply with the treatment
recommended by the health professionals. The ultimate goal of the proposed study is to
identify areas where further action should be made or ignored aspect that should be
considered future improving, strengthening of planning, managing and implementation of
the National TB Control Program (NTP). The unique feature of this study, its emphasis on
articulating the community factors side by side with the institutional factors that might lead
to foster the impact of NTP in Pakistan. The overall aim of this study can be sum up in a
way to evaluate the impact of the strategies envisaged in Pakistan to detect, treat, prevent,
and eradicate tuberculosis. More precisely the intended research aim at:
o To evaluate the relevance and effectiveness of the overall national strategy of the National
Tuberculosis control Program and its specificity to the Pakistani setting;
o Assessing the performance, TB case management in the public and private TB
centers/units in the three Districts of Northern Pakistan (NWFP) and also examining
planning, training, health education, communication; supervision, monitoring; resources
allocation and budget, and co-ordination with the private sector. Analyzing the available
institutional, human resources, regular drugs supply and laboratory materials;
o Assessing the adherence of TB patients with the prescribed regimens in the community as
well as their knowledge, attitude, practice of the TB patients,
o Nevertheless the dissertation is intended to provide key information and pertinent
references crucial to fortify skills for tuberculosis control specifically for Pakistan and
derive conclusions for improving international TB control for highly endemic countries
for example:
More specifically, the dissertation is expected to present technical knowledge essential for
TB control and formulate guidelines for the important but often neglected field i.e., case
management and programme management (i.e. the planning and implementation of control
activities from the central ministerial level, district, peripheral and community level).
Tuberculosis Control in Pakistan
Chapter 1
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Presented in Figure 1 this study encompasses a cross-design study coupling different
quantitative and qualitative methods to collect data about the tuberculosis control program
in Pakistan. The study includes three main components each is designed and implemented
in a way suitable to achieve one of the previously mentioned objectives.
 !"!!## ! $% ! &'#(&
"&( ! !)! This component includes review of documents and key informants
semi-structured interviews with various officials responsible for directing and
managing the National Tuberculosis Control Program. This component address issues like
relevance, coverage, financing, sustainability and impact of the program and aiming at
identifying problems encountered at the central level and suggesting direction for future
solutions.
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Tuberculosis Control Centers in the three districts within the North-West-Frontier-
Province of Pakistan (NWFP), where the highest prevalence of tuberculosis has been
recorded, were included in this component. Review of health/TB facilities done in each
first-level health care facilities in terms of numbers of patients registered, screening &
diagnostic facilities applied, type of treatment given, follow up, outcomes of treatment and
their back-up support and referral centers. Evaluation will also cover issues like manpower
development, financing, availability of drugs and supplies, monitoring, and surveillance of
tuberculosis. The output of this component is expected to be a review of the problems
encountered at the district level and suggestions on how to solve or eliminate them. The
role of private sector/ NGOs in TB control will also be evaluated.
.  $%'&&! $%&($! 
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TB patients taken from district Sawabi. Patients were interviewed using a semi-structured
interview format to assess their adherence by a) clinical examination; b) attendance/visits in
the TB unit and; c) adherence analysis by checking clinical records, urine examination and
verbal adherence. It was intended also to assess their knowledge regarding etiology,
manifestation, detection, prevention and treatment of tuberculosis. It also determines their
attitudes towards the locally provided services and their behaviors whenever a family
member had been infected with tuberculosis. The output of this component will be a
description of the believes and values attached to tuberculosis in the Pakistani cultural
context and community factors that can limit the success of the control efforts. Adopting a
Focused Group Discussion (FGDs) format the degree of patient·s adherence with the
treatment prescribed and factors (social, economic, cultural, etc.) that affected their
adherence were additionally appraised. The output of this component provided an insight
of perceptions and a description of the reasons as well as the social and mental
characteristics of patients who do not comply with tuberculosis treatment. This can guide
the control program towards higher risk groups of treatment failure and consequently with
higher probability of transmitting the infection to others.
Tuberculosis Control in Pakistan
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Tuberculosis Control in Pakistan
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The following data analysis methods were used in the study: Content and plausibility
analyses were used to verify whether or not the national strategy is expected to have an
impact on the tuberculosis problem in the community, Multivariate analysis (regression)
used to examine the statistical association between various variables (socio-economic,
demographic) and the adherence association between the characteristics of the health care
facilities in each district and their level of performance. The time schedule to achieve the
research aims given in the following however an additional time period of nine months
were required to complete the descriptive portion of the dissertation.

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A program review is an important occasion for promotion of the program within the
health services. Therefore, involvement of key persons from within the health services is of
a paramount importance. A simple management model for tuberculosis control is
presented in figure 2 with the main focus on three domains: the input into TB control, i.e.,
the resources; the implementation of the treatment delivery process; evaluation of the
output of the tuberculosis services, and attempts to predict the impact of tuberculosis
control activities on the epidemiological situation, i.e., the outcome.
Figure 2 Model for reviewing TB control activities
In order to obtain the support of political authorities and also to enhance prioritisation for
bringing systemic changes, a formal assessment scientific review with clear
recommendations was considered mandatory. The results of undertaken review are
intended to assist the process of planning, future activities and satisfy the financial needs of
the TB control program. The approach adopted, measures the impact of TB control at the
level of the patient care provider, the laboratory worker, the public health specialist and
other ´end usersµ who depend on our research for effective tuberculosis control.
Admittedly a yawning chasm that exists between the requirements of programme managers
and the needs of clinic and laboratory based health care providers, was focused. The public
health specialist needs simple diagnostics, safe treatment and robust monitoring and
evaluation, in other words tools that can be used for large populations. More important is
that the care and tools need to be simple, acceptable, inexpensive and universally available
for every individual in the society. On the other hand, individual patient care providers
crave higher-tech, state-of-the art instruments for individualized diagnosis and treatment,
regardless of price. Research organization, also do not satisfy the needs of the parent body,
funding agencies, and donors. These entities· requirements, as well as their benchmarks of
success, often diverge and produce a chaos in the system. This certainly makes hard to
achieve the targets and topple the priority problems. So there is a strong need to look into
all the issues of TB control, specially the balance and ultimate output and impact of all
inputs given to this particular task.