DECENTRALISED CARE FOR DR-TB:

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1 DECENTRALISED CARE FOR DR-TB: A complex disease requiring a comprehensive health system response Marian Loveday Presentation at FIDSSA Conference 7 November 2015

2 OUTLINE OF PRESENTATION Background DR-TB a complex disease Patient journey Decentralised vs centralised care Recommendations for effective care

3 South Africa: Nos of DS-TB and DR-TB: DS-TB DR-TB

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5 PROVINCE Eastern Cape Free State Gauteng KwaZulu- Natal Number of DR-TB patients treated in South Africa Table 1: MDR TB cases started on Limpopo Partner logo Mpumalanga North West Northern Cape Western Cape South Africa

6 DR-TB: A complex disease requiring a comprehensive health system response Household Family Health care workers Human Resources Procurement School Laboratory services Pharmaceutical Services Friends DR-TB patient Partner Electricity logo Work Transport services Audiology services Transport Social support/ Social worker Physical Infrastructure Roads Water

7 DR-TB A COMPLEX DISEASE Treatment DR-TB = 6 drugs + ART = 3 drugs Treatment Long 2 years Injectable for 6 months New drugs Adverse events Monitoring lab, CXRs, audiology, ECGs Limitations Challenges Personnel involved Routine hospital staff: doctors, nurses and cleaners Theatre staff Emergency care practitioners Pharmacists Radiographers Audiologists Social workers

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9 Research Question Is decentralised management of MDR-TB patients as effective as centralised care? Methods Study design: prospective cohort study comparing treatment outcomes in a centralised hospital with 4 decentralised sites (July June 2012) Primary outcomes Treatment outcomes and survival time

10 Decentralised MDR-TB management in KwaZulu-Natal: Comparison with treatment in a centralised setting Site 2 Site 4 Site 1 Centralised Hospital Site 3

11 BASELINE CHARACTERISTICS: DECENTRALISED VERSUS CENTRALISED SITES: 1 JULY JULY 2012

12 TREATMENT OUTCOMES: DECENTRALISED VERSUS CENTRALISED SITES: 1 JULY JULY 2012

13 SUMMARY Decentralised care is more effective than centralised care: Higher cure (50.7% vs. 34.3%, p < 0.001); Lower default (14.5% vs. 28.3%, p < 0.004); Earlier treatment initiation (72 vs. 92 days, p<0.001). Multivariate analysis: Treatment outcome at decentralised sites more likely to be successful (aor 1.43, P < 0.001)

14 TREATMENT OUTCOMES AT THE 4 DECENTRALISED SITES

15 Evaluating health system performance Domain Context Intervention Mechanisms Output Health systems factors affecting service delivery District level: Leadership, ownership + support Facility level: Ownership + support Integrated service delivery Human resources Support services Continuity of care Quality of care A conceptual and analytical approach to comparative analysis of country case studies: HIV and TB control programmes and health systems integration. Coker R, Balen J, Mounier-Jack S, et al. Health Policy and Planning 2010:i21 i31

16 Indicators to measure TB-HIV integration Health systems factor: Intervention Integration of MDR-TB and HIV services Criteria for measurement Integrated MDR-TB and HIV services Integrated clinical notes detailing MDR- TB/HIV patient management Indicators % co-infected patients who receive MDR-TB/HIV consultation and management at one desk % co-infected patients who do not queue at pharmacy. % MDR-TB clinical records which document Rx of HIV % MDR-TB clinical records that on discharge detail referral for ART.

17 Total health systems performance score per site

18 Context domain qualitative data Whenever we have a problem we phone the district TB co-ordinator. She is strict with us, but is also helpful. (Interview: Site 1: Nurse-in-charge of MDR-TB outpatients clinic) The district TB co-ordinator came to the opening of this MDR-TB unit But since then has never been near. Him and the hospital managers.they don t even know where the unit is. The hospital managers help with sorting out problems? Never, not one! (Interview: Site 3: Nurse-in-charge of MDR-TB outpatients clinic)

19 Two detrimental HR practices Acting managers I took up a problem that had emerged with the acting head of Site 4 MDR-TB unit. Well, I m only acting. I can t do anything. (Field notes and interview September 2010: Acting head of the Site 4 MDR-TB unit) Rotation of key clinical staff I am only working in the MDR- TB unit for 3 months. I haven t seen any guidelines. I follow what was done before. Dr. X who worked here before is around. I haven t spoken to him. He is busy, and so am I. (Interview with clinician at Site 2, April 2010)

20 RECOMMENDATIONS District level leadership and ownership; Supervision and support at district, facility and health worker level; TB/HIV integration; A good MDR-TB programme can only be present if there is a good TB programme; M & E treatment outcomes available at a facility level; Two detrimental HR practices: o Rotation of key clinical posts o Acting positions Adherence

21 Acknowledgements All MDR-TB patients, health care workers and managers in the TB programme, research collaborators and funders. Funders SAMRC Izumi Foundation A United Way Worldwide grant made possible by the Lilly Foundation on behalf of the Lilly MDR-TB Partnership. Contact details: Marian Loveday Marian.loveday@mrc.ac.za Thank you