Background

Multidrug-resistant tuberculosis (MDR-TB) refers to a type of TB that is resistant to two of the most effective first-line drugs: rifampicin and isoniazid [1]. Compared to normal TB, MDR-TB is more difficult to cure and creates a much greater burden to the patients. Because of longer treatment, poorer outcome and lager threat of transmission, MDR-TB is deemed to be a “communicable cancer” [1.

Fig. 1
figure 1

Roadmap of MDR-TB stakeholder identification and classification

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Data analysis

Epidata 3.1 (Jens M. Lauritsen, Odense, Denmark) was used to build a database with double entry and proofreading. The descriptive analysis was performed by Statistical Package for Social Sciences (SPSS) version 18.0 (SPSS Inc., Chicago, Illinois, USA). The median attribute scores of various stakeholders in three dimensions and the degree of expert authority were calculated by the two authors (KL and FW from the CDC) applying SPSS v.18.0. The recording of the interview was sorted into transcripts. Two of the authors (BC and KL) interpreted the answers by the experts and induced major interests and relationships among the stakeholders.

Results

Identified stakeholders of MDR-TB prevention and treatment

A total of 152 studies and 120 policy documents related to MDR-TB prevention and treatment were collected and reviewed. Based on current practice and policy documents as well as technical guides for MDR-TB control in China, the implementation system of MDR-TB control and prevention was synthesized, as shown in Fig. 2.

Fig. 2
figure 2

Implementation system of MDR-TB control and prevention in China. MDR-TB Multidrug-resistant tuberculosis, TB Tuberculosis, CDC Centres for disease control and prevention

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Based on the system and combined with document review, an initial list of 21 types of stakeholder candidates was developed and proposed (Table 1). According to the experts’ opinion, all the candidate stakeholders were approved (at least 70%), with a total of 17 candidate stakeholder categories receiving over 90% approval, including 11 categories receiving 100% approval. 4 candidate stakeholders had approval rates between 80 and 90%. The stakeholder groups of TB drug manufacturers, TB testing reagent manufacturers and TB testing equipment manufacturers were merged into one group called “TB-related products manufacturers”, as suggested by most of the experts. Finally, 19 types of stakeholders came up for the next round of analysis.

Table 1 The candidate stakeholder of MDR-TB
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Stakeholder attributes and classification

A total of 34 completed questionnaires were retrieved from expert surveys. All of the questionnaires met the quality criteria and were viewed as valid. The indicator “Ca” was 0.77, and “Cs” was 0.90. The total expert authority was 0.80, which indicates the reliability of the expert evaluation.

The median scores of specific attributes from experts are listed in the following table (Table 2). In line with previous studies, an attribute score greater than 3 is considered to have a corresponding attribute [8]. Following the principle of stakeholder classification, all of the stakeholders were categorized into three groups. Definitive stakeholders were those from the Department of Health Administration, Department of Medical Insurance, Department of Finance, and the Provincial CDC. Expectant stakeholders were MDR-TB patients and providers from the clinical department of prefectural TB hospital, administrative department of county-level TB hospital, county-level CDC, prefectural CDC, clinical department of county-level designated hospital, prefectural TB laboratory, community healthcare facility, county-level TB laboratory, Red Cross and other charity organizations. Latent stakeholders included family members and neighbours of MDR-TB patients and TB-related product manufacturers.

Table 2 The median score of the attributes of MDR-TB stakeholders based on the Mitchell scoring method
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Map** stakeholder relationships in the area of MDR-TB prevention and control

As seen from the map (Fig. 3), the colour in red, yellow and pink were applied to represent different categories of stakeholders. Definitive stakeholders such as the Department of Finance, Department of Medical Insurance, Department of Social Welfare, Department of Health Administration and the provincial CDC were at the top of the MDR-TB prevention system. They were considered to be policy makers and planners who coordinated the policy-making process. As policy implementers and practitioners, CDCs at the prefectural and county levels, TB-designated hospitals at all levels and community health centres would play the important roles in the MDR-TB control system. The clinical department and laboratory of TB have taken charge of patient diagnosis and treatment and they also reported case information to CDCs. The administrative department of hospitals should take responsibility for coordination between CDCs and hospitals. All of the CDCs and hospitals were regulated by the local Department of Health Administration. Higher-level CDCs would set technical guides for lower-level CDCs. The Red Cross and other charity organizations provided treatment subsidies and assistance to support MDR-TB patients. Community health centres have been responsible for MDR-TB patient follow-up.

Fig. 3
figure 3

Map of the stakeholder relationships among MDR-TB control and prevention in China. MDR-TB Multidrug-resistant tuberculosis, TB Tuberculosis, CDC Centres for disease control and prevention

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MDR-TB patients should be at the centre of the disease control system, and they have been the service targets of policy. They should be screened at county-level health facilities and referred, diagnosed and finally treated at prefectural TB hospitals. They should also be followed up by community health workers. Their family members and neighbours were potential caregivers and treatment supporters, and they might also monitor the self-managed isolation of patients in the communities. Manufacturers of TB-related products should produce and provide diagnostic equipment and reagents, anti-TB drugs and other necessary products for MDR-TB patients. They did not contact patients directly but had a close relationship with the disease control department and hospitals. The price of the products would ultimately affect the patients, health system and disease control.

Discussion

The MDR-TB epidemic has been the major challenge of TB control in China. In fact, the controlling work of MDR-TB involves stakeholders not only from medical departments at different levels but also from policy-making departments and non-government organizations. Stakeholder analysis has recently been widely used in the area of public health research, especially in policy research on AIDS and acute infectious diseases [16, 17]. However, there are few relevant studies in the area of TB or MDR-TB control to address low-case detection, limited treatment coverage and unsatisfactory treatment outcomes at present. Previous studies have shown that effective public health policies must meet the interests of most stakeholders [18]. To the best of our knowledge, this study is the first to apply the method of stakeholder analysis to identify the key stakeholders and to explore their attributes in the area of MDR-TB prevention and control. A stakeholder map was also developed based on their working roles and interactions to show the entwined relationships in the prevention and treatment of MDR-TB. These results can provide a reference for future policy-making and research on MDR-TB control in China.

Findings from this study showed that the Provincial CDC and government departments such as the Department of Health Administration, Department of Medical Insurance, Department of Social Welfare and Department of Finance had high scores in all dimensions of attributes, which is similar to the results of other stakeholder research [19], and indicates that these types of stakeholders must have a greater impact on policy development for MDR-TB control. The administrative department, which is at the top of the MDR-TB control system, has more resources and power for resource allocation. Nevertheless, some concerns remain. For example, these stakeholders have limited communication with the grassroots and insufficient information for policy-making, which leads to many problems in policy implementation [20]. Therefore, on the one hand, policy implementing organizations such as CDCs should promptly detect problems in the area and provide evidence-based solutions and suggestions to administrative departments. On the other hand, when administrative departments develop a health-related policy, they should also provide information and discussion time to all the stakeholders from the implementation organization and grassroots.

Our study indicated that among all expectant stakeholders, five types of stakeholders (MDR-TB patients, health providers in the clinical department of county-level designated hospitals, county-level CDCs, community health care facilities, and county-level CDCs) had one or two lower score dimensions, while the legality dimension had a higher score. Except for MDR-TB patients, the other four types of stakeholders are at the frontline of MDR-TB control and are mainly involved in the treatment and community follow-up of patients with MDR-TB playing an important role in disease surveillance and control of MDR-TB [21]. They might have many reasonable demands, while their suggestions have little impact on policy change, thus leading to the result of unsatisfied needs. Moreover, MDR-TB control work has potential risks of infection among these grassroots health workers, which could restrain their working enthusiasm [22]. However, at present, the lack of support of policies and measures for grassroots staff has led to a shortage of human resources at the frontline of TB prevention and control [23]. More attention should be given to the requirements and aspirations of frontline anti-tuberculosis workers during policy making.

In addition, this study showed that stakeholders such as relatives and neighbours of MDR-TB patients, and manufacturers had lower scores in all dimensions. Although they are latent or marginal stakeholders, they also play an important role in MDR-TB control in certain circumstances. The manufacturer who provides drugs, various reagents and medical devices for all patients is indirectly related to patients. The patient's relatives and neighbours, as part of the patient's social relationship, jointly take responsibility for the patient's health education and medication supervision; thus, they also play an essential role in the patient's treatment compliance and the prevention of MDR-TB transmission. Based on current policies, because many expectant and latent stakeholders seldom participated in the process of policy-making, we should strengthen communication with these marginal stakeholders such as primary health workers, patients and manufacturers, in such a way that they would voluntarily participate in the prevention and control of MDR-TB.

With a comprehensive definition and classification of MDR-TB stakeholders, this study proposes recommendations for policy-making for MDR-TB prevention and control. It also has great relevance to the prevention and management of other infectious diseases. With the socialeconomic development, China's major infectious disease prevention system has been much improved [24]. A stakeholder-oriented prevention and control policy-making system for infectious diseases should be established to make continuous progress on the prevention and control of infectious diseases. At the same time, we should enhance communication between the government, CDCs, TB hospitals, doctors, patients, manufacturers and other stakeholders. The interests of all stakeholders must be balanced in such a way that resources can be rationally allocated and the MDR-TB control system can function well.

There are some limitations in our study. First, the inclusion of key stakeholders is determined by the supportive attitudes of the experts and may be influenced by the subjective attitudes of the experts. Second, though the ten experts involved in the decision of the candidate stakeholders were from the national and provincial institutions, they may be lacking in terms of representation.

Conclusions

The MDR-TB control and prevention system was a multistakeholder cooperation system that was mainly led by government stakeholders. Enhancing the multisectoral cooperation was important for the policy-making process of MDR-TB control. First, the government department should involve more stakeholders in decision making for evidence-based suggestions, especially service providers at different levels. Second, different interests and relationships among stakeholders should be accounted for in the policy-making process. Last but not least, solid measures should be taken to empower more expectant and latent stakeholders, such as front-line service providers and MDR-TB patients, for their voluntary participation in policy-making for MDR-TB control and prevention.