Leading Voices: Daniel Gemechu

Meet Dr. Daniel Gemechu, MSH Regional Director for the USAID-funded Challenge TB Project in Ethiopia. MSH has worked in Ethiopia since 2011 to improve the quality of TB care and prevention services. Over the past five years, treatment success rates rose above 90%, with 75% of those suffering from multidrug-resistant TB (MDR-TB) now able to beat the disease after completing their treatment regimens. We asked Dr. Gemechu to reflect on his experience working with MSH and what remains to be done to eliminate the disease in Ethiopia.

What drives you to fight TB in your home country? 

It’s a truly impoverishing health problem. No one except those affected by TB can fully understand the pain and negative impacts the disease has on patients and their families. I was born in a rural community in southern Ethiopia where access to health services was limited, and I’ve also worked as a general practitioner and program coordinator, caring for hundreds of TB-affected patients. For many, TB treatment was prohibitively expensive, inaccessible, and stigmatizing. These are some of the reasons why I have committed myself to fight TB in Ethiopia and I sincerely hope—within my lifetime—to see an end to this epidemic.

In the early 2000s, the incidence of TB in Ethiopia was quite high, about 421 per 100,000 population. How has the TB burden in Ethiopia changed over the last 10 years? 

As we saw, back in the 2000s, not enough progress was being made to actively find and treat cases, improve laboratory diagnostic capacity, care for patients with MDR-TB, and so on. MSH started working with the Ministry of Health in 2011 under USAID’s HEAL TB Project to make high-quality TB and MDR-TB services accessible to over 50 million people in Ethiopia—more than half the country’s population at that time. At the start of the Challenge TB Project in 2015, which worked in 9 regions, covering 92% of the population, the incidence rate of TB was 207 per 100,000 population, which has declined at a rate of 7% every year to 164 per 100,000 population by the end of the project. These results are encouraging; Ethiopians now have better access to TB diagnosis, treatment, and medication, and we’ve seen a significant drop in deaths.

Tell me about a time when you saw this work in action. 

I remember traveling to a remote primary health care facility in Amhara region, which provides services to about 17,000 people. Early that morning, I went with the facility director to visit a community health post. The community health extension worker had brought in sputum samples of a suspected TB case in her village for testing using GeneXpert machines to diagnose TB. The machines were functioning as part of the nation’s diagnostic network because of the technical assistance the project provided to the facility. Despite being located in a rural area, they were connected to the larger national network with access to GeneXpert testing, and received the test results within 24 hours. The director explained how this testing leads to high quality, rapid diagnosis of TB, reducing the cost of travel for diagnosis and treatment, and ultimately, saving people’s lives. 

I was also impressed by the enthusiasm of a health extension worker I met serving in that remote area. She proudly described the package of services she provides to the households nearby, which includes health education about TB, TB screening, referring suspected cases, and providing treatment. She has a well-established and functional link with a group of female health volunteers that provide health services to her neighborhood. I was very impressed and wish to see these community-based services strengthened and continue across the country. 

When you look back on this work, what achievements stand out the most? 

MSH has a long history of working in close collaboration and partnership with the National TB Program, which has reached deep into the community. Contact tracing (a strategy used to find, test, and prevent TB in people who have come in contact with TB patients) and provision of preventive therapy for asymptomatic children under 5 have been very successful community-level interventions. It has progressed from policy to practice and is being scaled up throughout the country as a routine service included as a reportable indicator by health facilities nationally. 

Another example is the integration of TB services to childhood and other outpatient clinics—this is now standard practice. The practice and coverage of providing isoniazid preventive therapy for people living with HIV was low at the start of the project. In one of our regions, Tigray, this coverage has increased from about 40% at baseline to above 72% during the project period.

Other improvements, such as the decentralization of external quality assurance, the expansion and use of GeneXpert as the primary diagnostic test for TB, and increasing access to universal drug susceptibility testing, all contribute to finding a larger proportion of people with TB. The number of missing TB cases would be even higher if it weren’t for these interventions.

What keeps you up at night? 

Ethiopia continues to miss one-third of its estimated TB cases, despite the support to strengthen health systems and ensure a continuum of care. These cases could be among remote and rural communities and key affected populations, such as miners, prisoners, urban slums, people living with HIV, diabetics, etc. Most of these missing cases are among disadvantaged and impoverished communities who might be near a health facility but because of poverty, stigma, a break in the diagnostic chain, or protracted process, might not receive treatment or have poor quality of care. This cycle continues to further impoverish the community and creates conditions for further TB transmission. It’s the simple and innovative approaches that could break the cycle, either through policy makers, health care workers, or at the community level, that keeps me awake at night. 

What’s the next big hurdle to eliminating TB in Ethiopia?

We have invested so much to strengthen the health system to deliver quality, sustainable TB services—including services targeting drug-resistant TB—from national to provincial levels. The next steps forward are to look at health facilities on the periphery, transform district health services, strengthen community-based interventions, and break down social stigma, which is hindering TB elimination. We must introduce innovative, point-of-care tests and establish efficient sample referral mechanisms for communities. We also need to look beyond TB clinics and engage other actors beyond the health and private sectors to alleviate factors that contribute to catastrophic health care costs and make TB and other essential health services affordable and accessible to families. 

Do you think Ethiopia will beat TB? 

One day, I do believe this chain that hinders access and utilization of the available TB services will be broken: We will reach the missed cases, we will treat everyone infected and ensure effective prevention to declare a TB-free Ethiopia.