TB Reach

TB Reach Project

In 2018 AQUITY Innovations received a TB REACH wave 6 grant in order to contribute towards improved case finding. AQUITY Innovations is currently implementing a 1 year pilot project (referred to as AQUITY Innovations’ TB REACH Project hereafter) in NMBM that is engaging with the private sector. It is contracting a total of 10 GPs in sub-district C of the NMBM to provide free TB services in their own practices, including free TB diagnosis utilizing GenXpertin the government laboratory. A total of 30 community health workers (CHW), of who 29 are female, connects the GPs to their catchment areas. They conduct door-to-door screening and support the TB patient throughout the process. Team leads and a project manager support the CHWs, especially in terms of coordination and oversite. Throughout the project cycle the activities align with the coming NHI, in particular supplying free testing, contracting private GPs and employing CHWs.

This approach is innovative for the following reasons:

  • TB treatment in South Africa is currently only available in the public sector and not in the private sector
  • Private GPs in South Africa who have been contracted by the NHI to deliver other health services work from public health facilities and not in their own practices
  • Private GPs rarely use GeneXpert testing because tests are expensive and patients have to pay for it

The intervention site for AQUITY Innovations’ TB REACH Project is sub-district C in the NMBM and the control site is sub-district A. These 2 sites are comparable in terms of number of public health facilities, population size and number of TB patients detected annually. In August 2018, AQUITY Innovation’s TB REACH Project appointed a project manager, who had extensive experience working in the TB sector. She organized and facilitated meetings with key stakeholders, including GPs in sub-district C who were interested in the project. She presented the project to them, collected feedback and gained buy-in. From these meetings, a total of 10 GPs were recruited based on their interest and location. They were then trained by AQUITY Innovation’s TB REACH Project Manager on the national TB guidelines. A total of 20 female CHWs from the communities in the GP’s catchment areas were also hired and trained in active case finding. Topics covered included: door-to-door screening; sputum collection; recording and reporting; patient management and support; TB education and project management.

Furthermore, AQUITY Innovations’ TB REACH Project Manager identified key stakeholders including staff at government health facilities, HAST management, laboratory staff, taxi rank management, non-profit organizations and officials from other government departments. She is currently building and nurturing strong relationships with them. For example, the taxi rank management at Durban Road Korsten Taxi Rank is providing AQUITY Innovations’ TB REACH Project with a container at the taxi rank to screen taxi drivers and surrounding community members in. A PHC clinic close to the taxi rank is suppling the container with relevant equipment, testing kits and TB medicines as well as a lay counsellor to assist with doing additional tests.

In October 2018, AQUITY Innovations’ TB REACH Project team started testing patients, using the following process:

  1. CHWs conducts door to door screening in the community and screens people at the taxi rank
  2. CHWs tests people who screen positive for TB by collecting their sputa onsite
  3. CHWs takes the sputa to the PHC clinic or GP’s practice
  4. The laboratory fetches and tests the sputa using the GeneXpert
  5. CHWs goes to the PHC clinic in the morning to check the results from the GeneXpert
  6. If a patient tests positive for TB, the CHW finds him/her in the community
  7. The CHW counsels the patient and makes an appointment for the patient at a GP
  8. The CHW takes the patient to the GP
  9. The GP examines the patient
  10. The GP conducts HIV testing, if required
  11. If the GP diagnoses the patient with TB, he/she initiates treatment within 48 hours of screening
  12. If the GP diagnoses the patient with HIV, he/she refers him to a PHC clinic for treatment
  13. The GP, patient and CHW discusses and agrees on a treatment plan (normally the CHW fetches the patient’s TB medication from the PHC clinic for 2 months, takes it to the GP, fetches the monthly medication from the GP and gives it to the patient)
  14. The CHW monitors and supports the patient to take his/her TB medication throughout the treatment period of 6 months
  15. After 2 months, the CHW tests the patient for TB again and he/she has another appointment with the GP. If the patient converts at 2 month, the GP decreases the dose of TB medication and the patient takes that dose for the next 4 months. If the patient does not convert, he/she remains on the initial dose for another month until they convert
  16. In the 5thmonth, the CHW tests the patient for TB again and he/she has a final appointment with the GP. If his/her sputum remains negative, the GP discharges him/her on the condition that he/she completes their treatment

The launch

AQUITY Innovations’ TB REACH Project Team, together with the NMBM district and at the request of the Member of the Executive Council(MEC) for Health (Mrs. Helen August-Sauls), officially launched the project on the 22 March 2019. It was organized by a task force of different stakeholders including AQUITY Innovations’ TB REACH Project Team and officials from the MEC communication Unit, Municipality Communication Unit, DMT, Health Promotion Programs and NMBM Constituency Office for Special Programs. Together, the task force developed the program, invited relevant stakeholders and coordinated the logistics for the launch.

The launch was arranged into three activities on the day. The first activity started at the District office with all provincial and district managers. Betty Ncanywa, AQUITY Innovations’ TB REACH Project Manager, briefed the MEC and NMBM Public Heath Portfolio Councilor. Next, they proceeded to Durban Road Korsten Taxi Rank, where AQUITY Innovations’ TB REACH Project screens for TB patients at. Betty Ncanywa welcomed and introduced the stakeholders attending the launch, including (but not limited to): the MNC; MMC; MEC; taxi committee; taxi management; taxi association; PHC clinic facility manager; PHC clinic committee; provincial and district management; councilors; partners and the media. The MEC thanked the taxi and clinic committees for welcoming and supporting AQUITY Innovations’ TB REACH Project. She emphasized that this partnership was a “first-of-it’s” kind and should be replicated throughout the district. Both the taxi and clinic committees thanked the MEC and expressed how valuable AQUITY Innovations’ TB REACH Project is for them. Public health issues at the taxi rank, such as the unhygienic public bathrooms and illegal dumps, was also discussed at the launch and as a result have been resolved.

As part of the second activity, a small group of stakeholders visited the practice of Dr. Nojoko, a GP involved in AQUITY Innovations’ TB REACH Project. He explained the process of what happens when a patient in the project is referred to him. Dr. Nojoko stated that he is pleased that the project makes it possible for people who can’t normally afford his services to come see him. He also said that because of the training he received in the project, he is now screening patients for TB in his practice. The stakeholders were very impressed by the GP’s involvement in the project and thank him for it.

The third activity of the day was the actual launch, which took place City Hall. A total of 4 members of parliament attended the launch. In his welcoming speech, the Honorable Executive Mayor of NMBM, Councilor Bobani, congratulated AQUITY Innovations on the launch of their TB REACH Project. He thanked the MEC and AQUITY Innovations for involving the municipality in the launch and committed to supporting the project. He appreciated how TB REACH’s strategy of including the private sector in TB care is now playing a crucial role in complementing and supplementing government efforts in the NMBM.He said, “My office is always supportive of TB combating efforts intended to effect or bring about better living conditions especially to the poor by extending assistance or community health developments envisaged particular in depressed areas of our Metro (Bobani, 2019).” He stressed how important the partnership with GPs and CHWs are to actively screen people for TB because the government cannot do it without the assistance of partners. He also mentioned that in order to end TB in the NMBM youth programmes must be promoted. He ended by appealing to everyone to take an active part in developing the community they want and working together to achieve it. He said, “We must find solutions jointly to the TB challenges we face. We must assist government to meet its health development goals. Because without solving the health problems that confronts us, our development goals might be delayed or frustrated (Bobani, 2019).” Next, Dr. Nyathi, from AQUITY Innovations, presented the statistics from the project so far, which was met with a big applause. Dr. Tebelele, who is a GP participating in AQUITY Innovations’ TB REACH project, also shared his very positive experience of treating TB patients in his practice. He commended the project for enabling patients to be treated for free service in the private sector. The key note address was given by MEC for Health, Mrs. Helen August-Sauls, who commended AQUITY Innovations’ TB REACH Project for going “back to the basics” and screening door-to-door. She praised AQUITY Innovations’ TB REACH Project for testing people on site and following-up with patients who screened positive until the end of treatment. She said that district and provisional management and other partners could learn from AQUITY Innovations’ TB REACHProject, in particular how to involve the private sector and use CHWs.

Services on wheels were also provided for free by AQUITY Innovations’ TB REACH Project, the district and NGOs at the City Hall on the day of the launch. More than 2 500 people utilized these services at the launch, which included testing and screening for NCDs, STIs, TB and HIV as well as family planning and immunizations.

The success of the launch was demonstrated by the MEC hosting a meeting the following week and announcing that they want the project rolled across the district. Currently, the district is advertising for NGO to apply to provide WBOT services for the next financial year.

The results to-date

To-date, close to 100 000 community members have been screened for TB and over 5 000 have been tested for TB in AQUITY Innovations’ TB REACH project. Over 260 TB patients have started TB treatment, of which 49 have already completed their 6 month TB treatment.

Stakeholders’ experiences

A large number of different stakeholdersare involved in AQUITY Innovations’ TB REACH project. Some of them were interviewed and shared their experiences of the project so far.

What the main challenges in the NMBM?

High levels of poverty, unemployment, substance abuse and crime are all big problems in the area. Many people live in poor conditions, which are often over-crowded and poorly ventilated. They also do not have steady employment and struggle to support themselves and their families. They often rely social grants and may be in debt. A CHW explains further “We live and work in a difficult environment. Unemployment is linked to drug and alcohol abuse and crime. People (especially youth) become frustrated and use drugs and alcohol to escape. The bigger the drug and alcohol abuse problem becomes; the worse crime becomes because people rob others to get money to buy drugs and alcohol. It is not safe.”

Another key challenge is the lack of access to appropriate, quality and affordable healthcare. The PHC clinics are often located far from where people live and are difficult for them to travel to. Betty Ncanywa says “People need to wake up very early to go to the clinic. The clinics are often so far away that they have to pay a lot [of money] for transport. They also have to get to the clinics early to try and miss the long lines and waiting all day. It’s hard, especially if you are sick”. Some PHC clinics are over-burdened and under-resourced, which means regardless if people arrive early or not, they still have wait a long to be examined by a nurse and receive treatment. Sometimes they have to return the clinic multiple times to complete the examination, have tests done, obtain results and receive treatment. The PHC clinics are also only open during traditional working hours and closed on the weekend. “If a client comes to the clinic and has a job, they often can’t work that day because they are at the clinic for most or all of that day. Most of our clients who work are contract workers so if they do not work that day, they don’t earn money. They also risk losing their jobs if their employer is unhappy with them spending too long at the clinic or needing to come back many times,” explains a Ward-Based Outreach Team (WBOT)nurse, who is part of a PHC clinic’s team that works in the community. A patient, who was tested, diagnosed and treated for TB in AQUITY Innovations’ TB REACH Project, echoes this by saying “I need to drive my taxi and work, so I don’t have time to go to the clinic”. Patients also sometimes feel that the quality of care they receive at the PHC clinics can be improved, especially in terms of waiting time and resources available. These challenges contribute towards people having poor health-seeking behaving and only going to healthcare facilities once they are very ill.

What are the challenges related to TB in NMBM, apart from those mentioned above?

High default rates, lost to follow cases, co-infection and resistance to treatment all contribute towards the high TB burden in NMBM. As a result, people in NMBM are easily exposed to TB – especially in overcrowded and poorly ventilated houses, taxis and public areas.

Alcohol and drug abuse also drives the TB burden in NMBM. A CHW explains, “Alcohol and drug abuse makes it easy for TB to spread because many people drink in shebeens that are poorly ventilated. So, if someone in the shebeen has TB, other people can get infected. People also share bottles, cigarettes and broken bottle necks [to smoke drugs in] so TB can spread like that too.” Staff at a PHC clinic also says “Substance abuse also reduces compliance [of TB treatment]. It can be difficult to get patients who are abusing drugs and alcohol to complete their TB treatment.”

People feel that they will be stigmatized if they go to the PHC clinics because the clinics have specific days or areas for TB patients and that way people know who has TB nor not. An AQUITY Innovations’ TB REACH project team lead says “At the clinics patients don’t have privacy and they feel everyone will know that they are ill with TB. The stigma [of being ill with TB] is challenging in the community”.

Many of the people with TB in the NMBM are unemployed and come from very poor households. They cannot afford transport to the PHC clinics to fetch their medication and as a result stop taking their treatment. Similarly, they are unable to buy food to eat before taking their medication, which makes them feel very unwell. So, they stop taking their medication.

What were patients experiences like being identified, diagnosed and treated for TB by a GP compared to going to a PHC clinic?

Patients are reporting very positive experiences from being identified, diagnosed and treatedfor TB by GPs involved in AQUITY Innovations’ TB REACH Project. They like going to a GP because it is quicker, easier and more accessible. Betty Ncanywa explains “The doctors’ rooms are close to where the patients live and work, so it doesn’t take long to get there or cost a lot of money. They also don’t have to wait a long time to see the doctor, especially because we’ve trained the doctors to fast track patients who are coughing”. Patients who are working particularly appreciate that travel and waiting times are reduce becausethey still be able to work on the day they have a GP appointment. GPs’ practices are also open after hours in the week and on weekends, so they can go to GPs after work if they are unable to take time off work. GP can test them for TB and HIV in the appointment, so they don’t have to return to the GP’s practice at another time or go somewhere else for tests. Dr. Tebelele, who is a GP participating in AQUITY Innovations’ TB REACH Project, explains “Patients like it that in one setting I can do a number of things that will take long [to do] in a clinic”.

They also like that all the services – GP appointments, HIV and TB testing and TB medication – are free as they normal cannot afford consultations, tests or treatment in the private sector. Dr. Mtyoba, another GP involved in AQUITY Innovations’ TB REACH project, says “Patients who come to see me often don’t have money to pay for the tests or medicine. I had a patient who only took his medicine every second day to “stretch out” the treatment and make it last longer. So, patients like AQUITY Innovations’ TB REACH Project because it gives them an opportunity to be treated in the private sector [for free]”.

Patients are very pleased about the high quality of care they are receiving from the GPs involved in AQUITY Innovations’ TB REACH Project. A patient, who currently receiving treatment, says “The treatment [I get from the GP] is very good. I feel respected and get a full examination”. The patients appreciate that they can interact directly with the GPs and that the GPs can spend time with them, explaining things to them and answering their questions. “I have time to tell people about TB. That they don’t have to be scared because TB is curable”, says Dr. Mtyoba. Patients also like that at a GP’s practiceother people do not know why they were seeing the GP and that they do not feel like they will be stigmatized.

Apart from a patient being identified, diagnosed and treated for TB by a GP, what do you think the benefits of AQUITY Innovations’ TB REACH Project are?

AQUITY Innovations’ TB REACHProject contributes to successfully identifying, diagnosing and treating for TB patients who are lost in the TB care cascade. It also reduces the number of defaulters and “lost to follow up” patients. A WBOT nurse says “Because TB patients are being treated in the private sector, it’s decreasing the default rate and increasing the cure rate.”. This is echoed by the HAST manager for the NMBM district, Nadiana van der Bergh, who says “You just need to look at the statistics to see the success of the project. They speak for themselves – “missing” patients are being found and followed”.

The network of CHWs also contribute towards improving diagnosis and treatment by conducting door to door screening, linking the patients with the GPs and providing individualized support to the patient. A GP participating in AQUITY Innovations’ TB REACHProject explains “The CHWs play a very important role in the project, especially by picking up cases and supporting patients to complete their treatment”. The CHWs (supported by AQUITY Innovations’ TB REACHProject team leads and project manager) also help to ensure that the time between screening a patient and initiating treatment is under 48 hours. “We make sure we get the patients’ result quickly and they start treatment quickly”, says a CHW.

Patients are receiving top-quality health care due to AQUITY Innovations’ TB REACH team’s dedication and commitment. A WBOT sister says “The [AQUITY Innovations’]TB REACH team goes the extra mile for their patients. The CHWs visit their patients after-hours, if that’s when they are home”. Similarly, a patient says “I need to thank the [AQUITY Innovations’ TB REACH team’s] CHWs because they are very supportive. They are great.”

AQUITY Innovations’ TB REACHProject is giving different stakeholders opportunities to develop their skills and knowledge. Dr. Mtyobasays, “I have learned more about TB. It made me go back and revise what I learned about TB in med school”.

Strong and productive relationships are developing between diverse stakeholders as a result of AQUITY Innovations’ TB REACHProject. A WBOT nurse says “We are all working together and helping each other. The CHWs help us find the right patient because they come from the area. We help them with educating the community on other diseases. A lot of the time we go to a house together.” The clinic is also supporting the CHWs at the container by providing a lay counsellor to assist with doing additional tests as well as supplying the project with testing kits and medication. Betty Ncanywa describes these relationships further “We are working well with the clinic and WBOT teams and helping each other. I have already organizedthat the WBOT teams will follow up the patients who have not yet completed treatment when the project ends”. This is echoed by staff from the PHC clinic who says, “AQUITY Innovations’ TB REACH Project takes the burden off the facility and helps the client”. The GPs in the project also developing constructive relationships with healthcare professionals at the TB hospital and other government officials. Dr. Mtyobasays “I can now call the TB hospital and ask them for advice”. Very strong relationships are forming between the AQUITY Innovations’ TB REACHProject team and the local community. A team says proudly “The community respects us and are coming to us for advice”.

AQUITY Innovations’ TB REACH Project is also showing that public-private partnerships are effective and can help the district reach its health targets. “With NHI coming in, this project is a step in the right direction. We are ahead of others”, Nadiana van der Berghexplains.

Do you like being a stakeholder in AQUITY Innovations’ TB REACH Project and why?

It gives us a sense of purpose. A project lead explains “I like being a project lead because the work I am doing is making someone’s life better”. Similarly, a CHWs says “We love what we do. We touch people’s lives by testing them for TB, making sure they take their treatment and giving them counselling”. Dr. Tebelele also says “The project makes me happy because I am able to assist people who do not normally have access to GPs”. Furthermore, AQUITY Innovations’ TB REACH Project also provides much needed employment for women by hiring CHWs from the local community. A CHW says with pride “The project makes a difference to other people and our own lives. It has changed our lives for the better”.

Do you think AQUITY Innovations’ TB REACH Project should be extended and/or rolled out? If yes, what adjustments will you suggest?

Yes, AQUITY Innovations’ TB REACH project should be extended after September 2019 and rolled out throughout NMBM. But the extended and rolled-out project should offer a holistic and more comprehensive service. In this way the patients do not have to be referred to the government health facilities and the GPs can test them for non-communicable diseases (NCD) and treat for HIV and NCDs in in their practices. “Patients want a one-stop shop. They want to come to the doctor for everything” explains Betty Ncanywa. The GPs should also be trained to be able to initiate MDR-TB treatment. Another adjustment that can be made is to approach businesses to sponsor meals and travel costs for the most vulnerable patients.

As a stakeholder in AQUITY Innovations’ TB REACH Project what achievements so far are you most proud about?

“I am proud that from my 20 or so patients so far I have no “lost-to-follows”. Everyone is still on treatment. We need to use this approach in other settings to improve the success rates there as well.” – Dr. Mtyobo, a GP participating in AQUITY Innovations’ TB REACH project

“The project gives access to people who don’t have access to a private doctor and test. This talks to me. So, I am proud to be part of it.” – Dr. Tebelele, a GP participating in AQUITY Innovations’ TB REACH project

“I am proud of the very sick patients we identified and went out of our way to make sure they got treatment. They have now recovered and are doing good. I am also proud that we have good relationships with all the communities we work in. They accept and trust us, especially the taxi drivers” – Betty Ncanywa, AQUITY Innovations’ TB REACH project manager

“We are proud that patients are cured and we are saving lives. We are bringing change.” – CHWs from AQUITY Innovations’ TB REACH team (Left to right: Noluthando Mfini, Junaina Hendricks, Wendy Classen and Zoliswa Ntshoko)

“I am proud that AQUITY Innovations’ TB REACH project is making services more accessible. It shows public-private partnerships are working. With the NHI coming, it’s a step in the right direction” – Nadiana van der Bergh,HAST manager for NMBM [ The photo is of Nadiana van der Bergh with AQUITY Innovations’ TB REACH Project Manager and some staff from the district’s department of health. Left to right: Nadiana van der Bergh (HAST manager for NMBM), Betty Ncanywa(AQUITY Innovations’ TB REACH project manager), Zuki Mwanda (HAST manager) and Renea Berry]

Case study

My name is Levuyo. I live in an informal settlement. Most people there are unemployment. Crime, drugs and alcohol abuse is very bad. I am worried about the school kids. They are always at the shebeens. It is not good.

I live with my wife and 3 daughters. My little girl is only 1 year and 4 months. Two of my girls get child grants. My 3 brothers also stay with us. We live in a 4-roomed house and shack in the back. I keep my house neat and quiet. I am the only one in my family who is working. I am a taxi owner and driver. My taxi rank is [Durban Road] Korsten Taxi Rank. I drive 4 trips a day. There is not a lot of work (for taxi drivers in the area). There are too many of us.

I started coughing last year. I couldn’t go to the clinic because I have to work. I don’t’ have time to wait for hours. The clinic is too far from my work. I was very happy when the taxi committee at gave AQUITY [Innovations’ TB REACH project] a container to screen in. I went there one day after I drove my taxi for the morning. The team was very friendly. They made me feel good. They screened me and took my sputum. The next day when a CHW had my sputum results, she found me at my taxi. She took me to the container. And told me my sputum was positive. First, I denied it. I was thinking “Me? I don’t have TB”. But the team spoke to me. They educated me. They counselled me. And I accepted it. I said I would go to the doctor.

I went to the doctor the next day. I liked that a CHW came with me. And that I didn’t have to wait long to see the doctor. And that the doctor’s rooms are close to where I work. So, I could go between morning and afternoon rush hour and still work that day. The doctor was very good. He treated me well. I felt respected. He took his time to talk to examine me. He explained that I had TB but it could be cured. He put me on treatment. Because of my weight, he told me to take 4 tablet every day for 2 months. After 2 months, the CHW screened me at the container. She got the results and took me back to the doctor. The doctor examined me and looked at my [sputum] result. He was happy that my sputum converted. So, he told me to only take 2 tablets every day for 4 months. At the end of my treatment, I was screened and saw the doctor again. My sputum was negative and I was feeling much better. I picked up weight. The doctor was very happy and discharged me. I am happy that I saw the doctor 3 times for free.

I had to take my TB medicine every day for 6 months. Taking my medicine was very difficult at first. They made me feel sick. But me Betty told me to take my tablets after I’ve watched my game and before I go to bed. It made me feel better. I am very happy I finished my TB treatment, even though it was very difficult.

I fetched my medicine from the container each week. I just went there when I had time in my day. It was very easy. I didn’t have to go to the clinic. I really appreciate AQUITY [Innovations’ TB REACH project] team at the clinic. They accepted and supported me. We are friends now. They also organized for my family to be screened for TB at a clinic. Luckily, they all were negative. I was very happy, especially that my little girl didn’t have TB.

I am very thankful for AQUITY [Innovations’ TB REACH project] that I am cured. I wish other taxi drivers can be tested for TB, take treatment and get cured. I want the container to stay at the taxi rank. But it needs to be improved and have more services. Like testing for sugar and high blood pressure and HIV. And treating other illnesses and not just TB.

References

Bobani, M. 2019. Welcoming by Councilor Mongameli Bobani. 22 March 2019. Port Elizabeth, South Africa.

Department of Health Nelson Mandela Metropolitan (no date) 2018/19 – 2020 District Health Plan. Available at: http://www.health.gov.za/DHP/docs/DHP2018-21/Eastern_Cape/Nelson_Mandela_Metropolitan.pdf(Accessed: 17 July 2019).

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Municipalities of South Africa (2019) Nelson Mandela Bay Metropolitan Municipality (NMB). Available at: https://municipalities.co.za/overview/1/nelson-mandela-bay-metropolitan-municipality(Accessed: 15 July 2019).

Naidoo, P., Theron, G., Rangaka, M.X.,Chihota, V. M.,Vaughan, L., Brey, Z. O. and Pillay, Y. ‘The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges’, The Journal of Infectious Diseases, 2017:216, S702 – S713.

Nelson Mandela Bay Municipality Integrated Development Plan 2017/18 – 2021/22(Third Edition, adopted 19 June 2019). Available at: http://www.nelsonmandelabay.gov.za/DataRepository/Documents/2019-2020-nmbm-integrated-development-plan-adopeted-19-june-2019.pdf(Accessed: 5 August 2019)

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South Africa’s National Strategic Plan for HIV, TB and STI 2017 – 2022. Available at:https://sanac.org.za/wp-content/uploads/2017/06/NSP_FullDocument_FINAL.pdf(Accessed: 15 July 2019).

TB REACH (2019) About TB REACH. Available at: http://www.stoptb.org/global/awards/tbreach/about.asp(Accessed: 4 July 2019).

World Health Organization (2018a) Global Tuberculosis Report 2018. Available at: https://www.who.int/tb/publications/global_report/en/(Accessed: 4 July 2019).

World Health Organization (2018b) Millennium Development Goals (MDGs). Available at: https://www.who.int/news-room/fact-sheets/detail/millennium-development-goals-(mdgs)(Accessed: 2 August 2019).

World Health Organization (2018c) Global Tuberculosis Report 2018 – Graphic Country Profiles. Available at: https://www.who.int/tb/data/GTBreportCountryProfiles.pdf?ua=1(Accessed: 4 July 2019).

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