Preplanned Studies: Health Facilities and Treatment Service Models of the National Tuberculosis Program — China, 2010−2020

At the end of 2020, about 70% (2,069/2,960) of county areas had appointed general hospitals as their TB designated treatment center. The “trinity” service model had already become the primary trend in NTP, but many challenges still existed in the new treatment model.

In China, before the TB service system was transformed, most TB healthcare services including diagnosis and treatment were driven by TB dispensaries in CDC or independent TB centers (2). This kind of service system has played a great role in improving the detection of TB patients (3). However, it also led to many problems. First, patients were more likely to go to general hospitals rather than CDCs when they experienced TB-related symptoms. Second, many CDCs did not possess medical service licenses for clinical services, and the public health physicians in CDC were not qualified to provide clinical services. Meanwhile, the overall level of medical service and rescue capability of CDC were relatively low (4). Therefore, shifting TB diagnosis and treatment from CDC to general or TB/infectious disease-specific hospitals was an inevitable choice to provide better medical services for patients and to ensure the sustainable development of TB control.

The structural reform of China’s TB treatment service model has experienced a long but efficient process. After piloting in regional areas, the Ministry of Health (now National Health Commission) revised and established the new Regulations for TB Control and Prevention (5) in 2013, which established that designated health facilities should be responsible for diagnosis and treatment for TB patients while CDCs should be responsible for NTP management activities. Some indicators had been influenced at the beginning of the system reform, but they have rebounded and finally exceeded the numbers from before the reform (6). In addition, patient detection and treatment success rate were kept at a high level, which resulted in low mortality rates and the annual decreasing of the incidence rate was relatively more significant than global average (7).

Many counties and districts shared the same regional designated facilities. Some have been unified as one county-level management area in the NTP, but many areas were still independent. Therefore, at the county level, the total number of facilities were less than management areas. Currently, the majority of county level areas have shifted their TB treatment service models to designated general hospitals. After the “trinity model” was established, diagnosed TB patients could get more prompt notification, standard treatment, and effective management. In addition, a considerable part of designated health facilities remained in independent TB dispensaries or chronic disease stations in northeastern PLADs, Beijing, Tianjin, Shandong, Henan, and Guangdong where historically non-hospital TB treatment centers already have strong clinical capacities and less motivation to reform.

There were still many challenges existing in the new treatment model. Even when all public service providers were managed by the government, hospitals had different funding mechanisms in comparison with CDCs. The compensation investment for designated hospitals needed to be rationalized to reduce the economic burden of patients. Furthermore, TB control activities in designated general hospitals might also be influenced by other public health impacts. For example, during the COVID-19 epidemic in early 2020, many TB-designated hospitals were appointed as COVID-19 treating centers, which affected the diagnosis and treatment of TB patients (8). There were also many high-level health facilities that diagnosed more than 800 patients in 2020. These facilities were usually TB or infectious disease-specific hospitals. According to the design of hierarchical diagnosis and treatment, it was more conducive for TB patients to receive medication management and follow-up examinations at county-level designated facilities located in counties where they live in. The large amount of diagnosed patients at high level health facilities might influence the quality of full course patient management.

This study was subject to some limitations. The treatment service models were only evaluated at the county level. The service models at the prefectural and provincial levels should be further investigated and analyzed with patient referral mechanisms and drug resistance control. This study also lacked evaluation of treatment outcomes for each kind of model, which needs to be assessed in the future to better understand the barriers in different settings.

In the light of the requirements of national “Stop TB Action Plan (2019–2022),” the NTP should continue enhancing the collaboration mechanism between TB management institutions and designated health facilities at all levels. NTP also needs to explore more suitable treatment reimbursement mechanism and help them build an efficient referral system to provide quality treatment service for TB patients.

Acknowledgments: All participants of the national TB surveillance system. The China National TB Program and the National Special Science and Technology Project for Major Infectious Diseases of China (2017ZX10201302007).