Tuberculosis in Nepal: Status, Achievement and Challenges

Nepal is among the countries grappling with a high burden of TB for many years. In 2079/80, the National TB program reported 37,447 TB notifications in the country, with eight percent affecting individuals below 15 years old.

Dr Sampurna Kakchapati

  • Read Time 4 min.

Today is World Tuberculosis Day. Tuberculosis (TB) remains a significant global public health concern, impacting millions of people annually. Worldwide, TB ranks as the second leading infectious killer, surpassing HIV and AIDS and following COVID-19. As the world observes World Tuberculosis (TB) Day on March 24, 2024, under the theme “Yes! We can end TB,” it calls upon individuals and institutions to unite in the effort to eradicate TB. This day serves as a crucial moment to reaffirm commitments, inspire action, and rally efforts towards ending TB.

TB Burden and government efforts 

Nepal is among the countries grappling with a high burden of TB for many years. In 2079/80, the National TB program reported 37,447 TB notifications in the country, with eight percent affecting individuals below 15 years old. Among the total notified cases, 694 were drug-resistant. The concurrent spread of HIV/AIDS, along with the emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), has worsened the impact of the disease. According to the World Health Organization (WHO), Nepal ranks among the top 30 countries facing a high burden of drug-resistant tuberculosis. The rise of MDR-TB and XDR-TB poses further challenges to TB control in the country. TB not only affects individuals but also poses a serious public health threat to the entire country, being a leading cause of death among people living with HIV.

Nepal boasts a rich history in combating TB, dating back to the early 20th century. The establishment of the Tuberculosis Programme (NTP) marked first step in the nation’s sustained efforts to combat the disease. Through collaboration with regional and global partners, as well as healthcare providers, the NTP has made significant contributions to TB control. Integrated within the general primary healthcare system of the Government of Nepal, the National Tuberculosis Control Centre (NTCC) leads coordination efforts for TB control. It focuses on policy development, program implementation, capacity building, quality assurance, surveillance, research, and collaboration.

Major outcomes

Nepal’s Tuberculosis (TB) program has achieved significant milestones in recent years, boasting a consistent treatment success rate of over 90.0% consecutively. A notable advancement occurred with the introduction of the GeneXpert MTB/Rif assay for TB diagnosis in 2011, expanding coverage to 62 out of 77 districts and providing 17 GeneXpert XDR machines nationwide as part of the strategic plan. Additionally, Drug-Sensitive TB (DS TB) is now incorporated into the basic health services package, ensuring coverage for patients with Drug-Resistant TB (DR-TB) under the national health insurance scheme. Community support through Community-Based Directly Observed Treatment (CB-DOT) is available in selected areas, catering to both DS and DR-TB cases. The National Tuberculosis Program Management Information System (NTPMIS) serves as an efficient online web and case-based surveillance system, capturing comprehensive data crucial for monitoring and evaluation. Integration of DHIS2/HMIS systems facilitates aggregate data collection, while interoperability between eTB, DHIS2 Tracker, and IHMIS (DHIS2) ensures seamless data flow and analysis, bolstering TB control efforts. Additionally, two major surveys, the National Drug Resistance Survey and the Patient Cost Survey, provide essential insights for evidence-based decision-making and policy formulation.

Challenges and way forwards 

Nepal’s Tuberculosis (TB) program faces several challenges that hinder its effectiveness and impact. The major hurdles include the struggle to secure adequate funding for essential TB prevention, treatment, and care. A significant TB funding gap persists, and there is a lack of clear plans detailing how this funding gap will be addressed in the near future.

There is a shortage of Xpert cartridges, resulting in non-functioning GeneXpert sites due to delayed or insufficient supply and warranty coverage for module replacements. This shortage significantly disrupts diagnostic processes. Another persistent challenge is the substantial notification gap between TB case notifications and estimated incident TB cases. The National TB prevalence survey of 2018/29 estimated around 69,000 infected TB cases, yet the National TB program only enrolls, notifies, and treats 35,000 to 40,000 TB cases annually. This notification gap highlights the underreporting and under-diagnosis of TB cases, indicating that a large number of TB-affected individuals are not being captured by the health system.

Effective coordination and collaboration with other health programs and sectors, as well as multisectoral coordination, are essential to comprehensively address the broader determinants of TB. However, persistent stigma and discrimination against TB patients exist in certain communities, posing barriers to accessing care and support. Additionally, limited coverage and access to Community-Based Directly Observed Treatment (CB-DOT) and Family DOT services further challenge the program’s reach and effectiveness. There is also a pressing need to ensure social protection services for TB patients and their families. Furthermore, the lack of active involvement and participation of communities in TB Free Initiatives indicates a need to enhance community engagement strategies and initiatives to improve TB control efforts. Urgent action is needed to strengthen the utilization of data and evidence-based approaches in formulating policies and strategic plans for better interventions required to achieve expected outcomes.

The TB Free Nepal Initiative is a current government-led effort focused on strengthening local-level governance in combating TB. This comprehensive approach has made significant strides in enhancing local governance, mobilizing resources, and expanding its reach to 125 municipalities in 2079/80. Further expansion is planned, fostering collaboration between federal, provincial, and local governments, as well as stakeholders, to eradicate TB. This initiative offers a comprehensive approach to TB control, leveraging community engagement, data-driven policies, and strategic planning to effectively combat TB and work towards ending the disease.

Strengthening the ongoing TB Free Nepal initiative, enhancing full engagement with private providers, expanding TB services, engaging communities, and allocating local resources are essential keys to fighting against TB. Fostering collaboration between governments, stakeholders, and communities is critical to addressing this issue, as the government alone cannot combat the disease. This embodies the spirit of ‘Yes, we can end TB’.

(The writer is a public health researcher associated with HERD International. The views expressed in this article do not represent the organization he is associated with. He can be reached at [email protected])