Ethiopia could be a model country for tuberculosis control

Construction is booming in Addis Ababa. The skyline of Ethiopia's capital is dotted with cranes. Much of the city is a sprawl of building sites. Work on the metro, mostly financed by China, continues apace. The stretch leading south of the city centre opened earlier this year—sub-Saharan Africa's first light railway system. A railway connecting Addis Ababa to Djibouti, also funded by China, is expected to be operational next year. The huge US Embassy testifies to the interest the country excites in Washington. USAID describes its Ethiopian portfolio as “one of the largest and most complex in Africa”.

In all but two of the past 10 years, Ethiopia has seen double-digit economic growth, which has helped attract foreign investors to the country. But, except for its marketplaces, Addis Ababa does not feel overcrowded. “We have kept our farmers”, explains State Minister of Health, Kebede Worku. More than four-fifths of the Ethiopian population live in the countryside. The national airline flies to 17 domestic destinations. The population of Addis Ababa is less than 3·5 million, in a nation of close to 100 million people. In the clean and orderly heart of the city, where four-by-fours inscribed with the light blue lettering of UN agencies prowl the streets and multinationals hire hotel bars for their staff parties, it is easy to forget that this is an exceptionally poor country. GDP per head hovers at around US$485. 22% of the population live below the poverty line, and an astonishing 97% of the population manages on less than $10 per day—meaning Ethiopia has one of the smallest middle classes in sub-Saharan Africa.

Infectious disease burden

Its people are vulnerable to all kinds of infectious disease. Some of these are familiar: an estimated 730 000 Ethiopians have HIV. Others are barely known. Visceral leishmaniasis, deadly if untreated, affects 4500–5000 Ethiopians every year. And yet others have been widely forgotten: the country reports around 4000 cases of leprosy every year. Low levels of urbanisation have probably dampened the spread of tuberculosis—those who migrate to the cities of sub-Saharan Africa usually live in wretched and congested conditions. Nonetheless, Ethiopia has the world's tenth largest burden of tuberculosis, and is one of 27 high-burden countries for multidrug resistant tuberculosis (MDR-TB). But its unwavering commitment to control efforts has prompted experts to suggest that it could serve as a model country.

National tuberculosis programmes across the globe are settling into the post-2015 agenda. The End TB Strategy, which will run until 2030, envisages universal health coverage and social protection, alongside ambitious goals for cutting mortality by 90% and new cases by 80%. Ethiopia has detected and treated some 1·5 million cases of tuberculosis over the past 20 years. It has reduced mortality by 63% and prevalence by more than 50% since 1990 (worldwide, mortality fell by 45% and prevalence by 41% during the same period).

Last year, Ethiopia saw around 140 000 cases of tuberculosis, which probably amounts to two-thirds of the total burden. Roughly 90% of patients with drug-sensitive tuberculosis were successfully treated. There were 597 cases of MDR-TB. Treatment success rates for MDR-TB are a remarkable 78% (worldwide, the rate is 48%). The country has been a keen adopter of Xpert MTB/RIF testing, which takes a few hours to diagnose tuberculosis and determine whether the bacillus is resistant to rifampicin (a proxy for MDR-TB). A laboratory diagnosis of tuberculosis would otherwise necessitate a technician reading a sputum-smeared slide through a microscope for 15 minutes. For an untrained or unobservant technician, the bacillus is easy to miss.

Political will

There is genuine political engagement. “Flagship programmes are identified and monitored at a high level”, explains WHO's Esther Aceng, who is based in Ethiopia. “Everybody is held accountable, including the minister, and everybody is interested in seeing the indicators improve.” There are comprehensive 5-year plans, with clearly delineated objectives. The plans are strictly adhered to; corruption, at least in the health-care sector, seems to be minimal. “When the leadership in Ethiopia asks for money from donors, they are listened to because of the sincere commitment they have reflected in the work they have already done”, UN Special Envoy for Tuberculosis, Eric Goosby told The Lancet. Donor money is set to work in implementing the Ethiopian plan, rather than being diverted into parallel systems. “There is one plan, one budget, and one monitoring system—it is very rare to have that happen”, said Goosby.

“When this government says it will do something, it does it”, adds Mario Raviglione, director of WHO's Global TB Programme. Ethiopia was the first African nation to fully integrate tuberculosis care into its health system. Services are decentralised, with almost 3000 facilities providing diagnosis and treatment, all of which are free. Almost all patients are treated at home; they just attend the clinic once a month to collect their drugs. The importance of this should not be underestimated: tuberculosis requires 6–8 months of daily medication, and health centres are commonly several kilometres from patients' homes.

The national authorities do not have trouble imposing their writ on the regions. In other countries, state and federal governments are often at odds, but this is a government with a firm grip on power. In June's parliamentary elections, prime minister Hailemariam Desalegn's Ethiopian People's Revolutionary Democratic Front (EPRDF) won all 546 seats. Human Rights Watch has accused Desalegn's regime of using “arbitrary arrests and politically motivated prosecutions to silence journalists, bloggers, protesters, and perceived supporters of opposition political parties”.

The USA and European Union offer more muted criticism, but the security and predictability offered by the EPRDF is mostly welcomed. After all, this is a troubled region. The war-torn countries to the east and west, Somalia and South Sudan, are barely states at all. Historically cordial relations between Ethiopian Christians and Muslims, and the predominance of moderate branches of Islam, have helped Ethiopia avoid the terrorist atrocities that have hit neighbouring Kenya and Somalia. It is well-set to realise its ambitions of becoming a lower-middle-income country by 2025. And for complex public health interventions such as tuberculosis, stability is crucial. “I have struggled for most of my career over what to do in settings where the government is not in control or is unwilling to engage on difficult problems”, said Goosby. “The Ethiopians are very willing to talk openly about the challenges they face.”

Health extension workers

Still, while stability and planning may be in short supply in east Africa, what really singles Ethiopia out is its delivery. A group of some 40 000 trained health extension workers provide basic health-care services in a country with three physicians for every 100 000 people. The workers are employed by the government. Drawn from their local community, in agricultural regions they are invariably women—it is very difficult for men to gain entry into rural households, especially if the husband is out. Moving from house-to-house, they offer advice and a range of interventions on matters such as HIV/AIDS, nutrition, vaccination, family planning, and health education. “It is a professional service, so there is no reason for it not to continue, and the quality of services that they are providing will continue improving as we go along”, Worku told The Lancet. “It is sustainable and fully integrated into the community.”

There are two health extension workers for every 500 households. A roughly equal number of community volunteers augment their work. According to official statistics, 77% of tuberculosis cases in Ethiopia were initially referred by health extension workers (although there may be some double-counting here). “The workers are positioned in the lowest administrative unit—they would not see more than five to six cases of tuberculosis, so patients are easy to follow”, explains Aceng. “That is why you see these tremendous results.”

As well as referring potential cases, workers nudge patients into completing their course of treatment. The Ethiopian Government is upgrading the level of training of these workers, and Worku talks of eventually making them into family physicians. That would be quite something. In Wonchi, a rural settlement 2 hours' drive from Addis Ababa, a pair of extension workers talked of the job. The hardest time is the rainy season, said one, when every day they have to walk for 2 hours on tracks that are little more than mud. All for around $100 per month. The women are in their mid-twenties, but the median age in Ethiopia is 18 years. This is a young country abounding with energy. With the right stewardship, it can overcome far more than tuberculosis.

Source: The Lancet