But long-standing weaknesses in management and organisation, compounded now by the federalisation process, have allowed some of the essential functions of the NTP to disintegrate, and others are at serious risk. The laboratory network for diagnosing TB and the system of supportive supervision that ensures standards are maintained through all levels of government should be restored immediately.
This is because district centres, key to TB control strategies, were abolished — and then reinstated — but with far fewer staff than previously.
Accurate surveillance of the cases notified and the flow of information to the centre is endangered. Federalisation has so far not created clear mechanisms that will ensure these essential functions continue. If decentralised procurement of drugs continues, it will increase procurement costs significantly and risk the purchase of poor quality drugs.
Successive governments have allowed the technical staff of the National TB Centre to be hollowed out, eroding its capacity to develop policies and lead their implementation. The National Strategic Plan, written three years ago, is underfunded and only partially implemented. Most staff responsible for TB activities are now not trained to carry out the work.
Diagnosis is mostly by outdated and insensitive sputum microscopy. Transport of specimens to laboratories is still inadequate. Consequently, GeneXpert utilisation has been slow to increase.
The private health sector is massive and growing. Over 70% of people with TB first go to private clinics, yet diagnosis and treatment are of variable quality, leading to drug resistance.
The joint monitoring mission recommended the following:
Stop the collapse of the NTP by engaging the MOHP in discussions on federalisation to ensure that the essential functions of TB control are preserved, with clear roles and responsibilities for the newly appointed staff.
Increase investment to provide technical support to all levels of the NTP through teams of staff at central and provincial levels. Let a partner employ these staff if the government cannot do so immediately.
Use these teams to address the massive training gap that hypermobility of staff and federalisation have created.
Phase out sputum microscopy for diagnosis and move to GeneXpert testing, and make sure contracted organisations achieve case-finding targets. If they do not, stop the activities and redirect the resources to more effective areas.
Fully engage with the private sector to ensure patients there are diagnosed and treated according to national guidelines.
Similarly engage with community-based organisations to help find cases and ensure they finish treatment.
Nepal must act on all these recommendations without delay to get back on track to meet its commitments.
Paul Nunn was Team Leader of the international mission and Bhim Singh Tinkari is a recent Director of the National Tuberculosis Centre