Engage, Equip and Empower all health workers to End TB

By guest contributors Joel Shyam Klinton, Neha Rastogi, Zolelwa Sifumba, David Bryden, Poshan Thapa, and Petra Heitkamp

Given the progress made in saving lives (74 million since 2000), the goal of ending TB seems achievable. However, many health systems, particularly those with a high burden of TB, are still far from meeting the targets set out in the WHO’s END TB Strategy¹. Achieving such a large-scale effort requires comprehensive and coordinated engagement of the entire healthcare workforce from both public and private sectors. Yet this is a workforce that has been under enormous strain in recent years, with accelerating migration of health workers further aggravating already existing shortages.² As we commemorate World Health Worker Week following closely on World TB day, it is crucial to remind ourselves of the need to engage, equip, and empower health workers to bring an end to TB.

Engage all health workers:

We cannot reach the End TB Goals without all hands-on deck. The health workers involved in TB services encompass a broad spectrum, ranging from the first point of contact when seeking care for a cough – which is often the pharmacist, community health worker or private doctor – to physicians, nurses, and other staff in large hospitals, laboratories, and clinics. The behaviour of people seeking healthcare can be complex, especially when the formal health system is fragmented and difficult to access for a significant portion of the population. This situation is further compounded by the existence of private sector dominance in the health market. As a result, people may seek care from a variety of health workers, often first with private health providers. This underscores the need to involve all health workers in TB care, while ensuring that they have the necessary support, training, remuneration and access to TB tools to be ready when needed and can provide quality care.

Engaging all healthcare workers is also crucial for TB care due to the nature of disease, requiring continuous care from identification to cure as well as prevention. People’s preferences and cultural beliefs influence care-seeking from formal and informal, private, and government healthcare providers. Limited access to formal healthcare creates gaps for private health workers in many high TB burden countries. Private healthcare providers are necessary to offer significant healthcare services.

Several projects have been implemented to engage the private health sector in TB prevention and care. These projects have proven to improve the TB services in their respective regions.³ Therefore, engaging all healthcare health workers expands access to TB care services and ensures a people-centered approach to TB care.

Equip all health workers:

Primary healthcare workers are often overlooked, and private healthcare workers even more so. During the COVID-19 pandemic personal protective equipment, vaccines and diagnostics were provided to public health workers first. Although the WHO PPM guideline emphasizes the importance of engaging all private health workers, in reality within the overburdened TB programs, private sector engagement is often limited.

Exciting developments in TB care, such as shorter treatment regimens⁴, AI-based tools⁵, point-of-care diagnostics⁶, vaccines⁷, and dashboards⁸, are on the horizon. To fully realize the potential impact of these tools, it is crucial to ensure that they are equally available to all health workers, as well as to all community members, irrespective of where they seek care.

Empower all health workers:

The Global Plan to End TB 2023-2030 envisions a crucial role to be played by community health workers⁹. It notes the dramatic difference these workers can make when fully engaged, but rightly states that their labor is often unpaid and urges that their roles be formalized. Evidence suggests that COVID-19 has caused massive disruption to the education and training of health workforce¹⁰, while many experienced health workers are leaving their positions or emigrating.¹¹ We need to strengthen and improve training, while also ensuring sufficient investment that will incentivize trained workers to stay on the job, including dignified working conditions and reliable, fair compensation. WHO estimates that women account for about 70% of the global health and social care workforce, emphasizing gender equity issues (work free from discrimination, harassment, gender pay gap; etc) needing to be addressed when building resilient health systems.

Community health workers and private providers each have unique roles in ending TB. The Global Fund has now incorporated a funding indicator for both groups¹², which will enhance planning and accountability at the country level and ensure that all healthcare workers are involved. Typically, disease programs concentrate on providing specific services, whereas the establishment of effective and resilient health systems is often given less priority. It can be argued that strengthening these disease-specific structures also contributes to the development of the workforce and surveillance capacity for the whole health system. However, it is crucial to prioritize clearly defining the individual tasks and competencies of the health workforce and analyzing their contributions to TB services. Investing in the TB workforce contributes directly to Universal Health Coverage (UHC) and pandemic preparedness and as such health workforce is at the core of the three UNHLM discussions this year.¹³

Frontline healthcare workers, community health workers and private providers play important and distinct roles and need to be at the heart of End TB efforts.

References

1. The End TB Strategy. World Health Organization. 2015.
2. Kaveri M. WHO Raises Alarm Over Increased Healthcare Worker Migration to Rich Countries Post Pandemic. Health Policy Watch. March 2023.
3. TBPPM Features. TBPPM Learning Network. Available at https://www.tbppm.org/page/tbppmfeatures accessed on 22 March 2023
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5. Qin ZZ, Ahmed S, Sarker MS, Paul K, Adel ASS, Naheyan T, Barrett R, Banu S, Creswell J. Tuberculosis detection from chest x-rays for triaging in a high tuberculosis-burden setting: an evaluation of five artificial intelligence algorithms. Lancet Digit Health. 2021 Sep;3(9):e543-e554. doi: 10.1016/S2589-7500(21)00116-3.
6. Hong JM, Lee H, Menon NV, Lim CT, Lee LP, Ong CWM. Point-of-care diagnostic tests for tuberculosis disease. Sci Transl Med. 2022 Apr 6;14(639):eabj4124. doi: 10.1126/scitranslmed.abj4124.
7. TuBerculosis Vaccine Initiative (TBVI) . Pipeline of vaccines, 2022. Available: https://www.tbvi.eu/what-we-do/pipeline-of-vaccines/ [Accessed 03 Mar 2023].
8. Prevent TB digital platform: Dashboard. Global TB Programme. 2022.
9. The Global Plan to End TB 2023-2030. Stop TB Partnership. 2023.
10. Dedeilia, A., Papapanou, M., Papadopoulos, A.N. et al. Health worker education during the COVID-19 pandemic: global disruption, responses and lessons for the future—a systematic review and meta-analysis. Hum Resour Health 21, 13 (2023). https://doi.org/10.1186/s12960-023-00799-4
11. Recover to Rebuild: Investing in the Nursing Workforce for Health System Effectiveness. International Council of Nurses. March 2023
12. Modular Framework Handbook Allocation Period 2023-2025. The Global Fund. December 2022.
13. Akselrod S et al. Getting health back on the highest political agenda—the UN High-level Meetings on health in 2023. Lancet Glob Health 2023.

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