Ending tuberculosis in the sustainable development era in China: what are the health system challenges? A mixed-methods study.

The UN Sustainable Development Goals include ending the tuberculosis epidemic globally by 2030. China is a high burden country of both drug-susceptible and multidrug-resistant tuberculosis. This study examined China's progress in meeting the tuberculosis milestones and targets laid out by the WHO End TB Strategy, and analysed key health system challenges to be overcome towards ending the tuberculosis epidemic in China. We used estimates of tuberculosis incidence and number of tuberculosis deaths in China from the Global Burden of Disease Study 2016 to conduct current situation analysis and a projection for 2030. We also reviewed national strategy and implementation guidelines in relation to tuberculosis control in China. We conducted semi-structured qualitative interviews, including key-informant interviews with decision makers and policy implementers at national and provincial levels (n=4), and in-depth interviews with experts in tuberculosis control (n=3). Senior researchers invited participants to take part in interviews through personal contacts, and undertook the interviews after obtaining verbal consent from the participants. Thematic analysis was applied to identify themes and develop interpretations. Between 1990 and 2016, the estimated tuberculosis incidence declined from 156 cases per 100 000 individuals to 86 cases per 100 000 individuals, and the number of tuberculosis deaths decreased from 178 515 to 40 120, in China. The tuberculosis incidence was projected to drop to 62 cases per 100 000 individuals, and the number of tuberculosis deaths to drop to 17 218 by 2030, both above the WHO 2030 targets of an 80% reduction in tuberculosis incidence (17 cases per 100 000 individuals) and a 90% reduction in the number of tuberculosis deaths (4130), compared with 2015. Of the four key informants, three said that many patients with tuberculosis, particularly multidrug-resistant tuberculosis, suffered from catastrophic payment for tuberculosis care. Qualitative interviews also revealed several key health system challenges in the access to high quality and affordable tuberculosis care, including: (1) insufficient funding and workforce for tuberculosis control; (2) difficulty in scaling up new tuberculosis and multidrug-resistant tuberculosis diagnostic tools; (3) inefficient cooperation across anti-tuberculosis health facilities; and (4) inconsistency among health insurance policies, public hospital reforms, and tuberculosis control strategies. China cannot meet the End TB Strategy targets by 2030, unless synergistic tuberculosis control policies and strategies can be developed and implemented, and multi-sector cooperation can be improved to enhance the delivery of tuberculosis care. The Bill & Melinda Gates Foundation (grant number OOP1148464). [ABSTRACT FROM AUTHOR]