On March 18, 2014, The Lancet, one of the world’s top medical journals, published a paper that documents the tremendous progress that China has made with tuberculosis (TB) control and treatment in recent decades (1990-2010). The paper revealed an astounding figure: TB prevalence in China has declined by an astounding 65%.
According to China’s Centers for Disease Control and Prevention, this result was the outcome of 5.3 million people gaining access to timely, high-quality TB treatment, which prevented 40 million people from being infected with TB.
The paper’s findings are based on three nationwide TB prevalence surveys. Ever since China scaled up its national TB control program, using directly observed treatment, short-course (DOTS), it has conducted national prevalence surveys every 10 years (1990, 2000, and 2010) to monitor progress. This has made China the only country in the world that has consistently measured the impact of its DOTS strategy.
At the Bill & Melinda Gates Foundation, we call ourselves impatient optimists, and The Lancet paper justifies optimism that we can defeat TB with scaled, innovative, and evidence-based TB control and treatment.
The paper tells us not only what happened, but also how it happened:
- First, China’s approach to diagnosis and treatment changed. After the scale-up of DOTS, China started applying microscopy to screen TB patients and started standardizing first-line drug treatment, which controlled the infectious source and prevented TB patients from becoming drug-resistant TB patients.
- Second, the system for TB control and treatment changed. There was a massive shift from TB patients receiving treatment from hospitals to receiving treatment from the public health system, which adopted standard DOTS. This institutional change ensured the promotion of standardized TB treatment and good follow-up of patients until they finish treatment, which typically takes 6-9 months.
- Third, the financing of TB care changed. By providing free diagnosis for all suspected TB patients, as well as subsidized treatment for all TB patients, everyone with TB was assured to receive timely standard treatment. According to data from China’s CDC, the total investment for TB patients’ free diagnosis, treatment, and management was around 3.1 billion RMB (US $500 million) from China’s central government, 2.8 billion RMB from local governments, and 2.3 billion RMB from international partners.
These findings are critical to improving global TB control efforts. As a high TB-burden country, China halved the burden of TB cases and deaths by implementing a modern TB control program a full five years ahead of the global goal set by WHO. Moreover, China achieved this dramatic impact using old approaches. Today, with much better tools - diagnostics, drugs and adherence technologies that address current gaps in TB control, especially drug-resistant TB, we can be optimistic that the impact seen in China can be not only replicated in the rest of the world but even improved.
China’s TB control efforts still face many challenges. A large population of TB-infected people remains, and a serious TB epidemic continues in western and rural China. Moreover, China is shifting its TB diagnosis and treatment efforts back to hospitals, which brings new challenges. Some hospitals fail to report new TB cases in a timely way, and the system managing TB treatment between hospitals and the CDC has not been fully established.
To help address these challenges, a partnership between China’s National Health and Family Planning Commission and the Gates Foundation will pursue a three-pronged approach:
- To promote the use of innovative diagnostics and treatment approaches,
- To reduce the financial burden of TB on patients and their families by promoting innovative financing and payment mechanisms, and
- To promote effective collaboration between China’s CDC, public hospitals, and community health facilities.