Current status of integrated community based TB service delivery and the Global Fund work plan to find missing TB cases

Transcription

1 Current status of integrated community based TB service delivery and the Global Fund work plan to find missing TB cases Tanzania Dr Peter Asilia AMREF

2 Background Tanzania is one of 30 highest Tuberculosis burden countries in the world. In 2016: 65,908 (40%) TB cases were notified (out of the estimated annual incidence of 160,000 cases) and initiated Anti-TB; this implies 90,000 TB cases missed. 158 MDR TB cases were initiated treatment out of 196 detected cases (estimated annual case incidence 830 MDR TB). 672 MDR TB cases missed Community based TB activities are designed to sensitize/mobilize for community engagement in identifying TB cases; TB diagnosis using Lay counselors and sputum fixers; and early referral to HFs for TB treatment and support National coverage of community based TB activities is 100% (185 Councils). Activity varies base on the type of available support.

3 Key community stakeholders with coverage Cadre implementing community based TB activities in the country NGO/other CBOs/Minis try of health/ other Responsible agency Community volunteers CBOs, KNCV - Challenge TB Community AMREF Global Fund Volunteers (Ex TB patients/ Sputum fixers), Traditional healers) Gov Community Volunteers (Ex TB patients/ Sputum fixers Community Health volunteers CSOs USAID Boresha afya Geographic coverage 6 regions (47 councils) 8 regions (55 councils) 3 Regions (17 councils) Amount of funding allocated in $630,061 $2,191, No clear data CBO LHL 7 councils No clear data

4 MAPPING OF PARTNERS ON COMMUNITY TB INTERVENTIONs IN TANZANIA 2018/2020 Global fund Deloitte, Tanzania KNCV TB Foundation, Tanzania EGPAF, Tanzania The Norwegian Heart and Lung Patient Organization

5 MAPPING OF COMMUNITY HEALTH VOLUNTEERS 2018 Key EX-TB Clubs Sputum fixers

6 Implementation mechanism Entity Implementation arrangement Resources Implementin g cadres Salary/incen tives/other NTLP/ AMREF Selection of CHVs Training in collaboration with NTLP Support (Incentive and monitoring) $2,191,080 (7.5% of total budget) CHVs (Ex TB patients, sputum fixers) and Traditional Healers Sputum fixers ($25 monthly allowance, $10 transport allowance) Ex TB patients

7 Implementation mechanism TWG CSOs MoH NTP/AMREF KNCV DELLOITE EGPAF DISTRICT MEDICAL OFFICER HEALTH FACILITIES COMMUNITY HEALTH VOLUNTEERS Coordination Define Strategies/interventions Support Implementation through funding, M&E tools and governance Supervision and Training Report analysis and quality Improvement Ensure Accountabilit y during implementati on Oversee all the activities related to TB in the district - Identify CHVs (ex-tb patients, sputum fixers and Traditional Healers) - Prepare budget for implementation (transport and monthly allowances; incentives) - Oversee day to day functions of CHVs - Must have tools necessary to implement activities - Must report every week - Must ensure the Village Health Committee is aware of all the TB community activities

8 Item Support from national TB programme Support for implementation Support Technical assistance Guidelines and tools Training facilitators Equipment and supplies especially for sputum fixers Training/capacity building strategy for CHWs/CVs Supervision mechanism Monitoring and evaluation of CHW/CV performance Training/ Refreshers on the start of the intervention Mentorship conducted during quarterly meeting Provision pf Community TB care handbook in Swahili Provision of IEC materials Annual Joint supervisions NTLP and Partners Semi-annual regional supervision Quarterly data verification meetings

9 Available implementation tools (please use actual pictures where possible) Document Existence 1 National guidelines for community based TB activities 2 Referral mechanisms and tools (for presumptive TB) 3 Job aids for referral, diagnosis and treatment of TB YES YES (Form TB 15) YES (SOP for sputum fixers, Handbook for CHWs) 4 Recording and reporting tools YES (TB12, TB13 A&B, TB14, TB 15) 5 Tools to ensure treatment completion and patient support TB 02, TB 13B 6 Any others? National ENGAGE TB Operational Guideline YES

10 Community TB Guidelines documents

11 Community TB M&E tools Wizara ya Afya, Maendeleo ya Jamii, Jinsia, Wazee na Watoto Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma TB 12 Fomu ya watu (wateja) waliofanyiwa uchunguzi wa awali wa TB na DR-TB katika Jamii Jina la Mwanakikundi/Mtoa huduma za afya ngazi ya jamii.. Jina la Kikundi/Asasi Jina la kitongoji /Mtaa..kata..wilaya.. Mwezi wa kutolea taarifa(mm/yy) / /. Na Tarehe Jina (majina matatu) Jinsi (me/ke) Umri (miaka) Namba ya simu ya mteja Namba ya simu ya mtu wakaribu Mahali alipotokea mteja/alipohojiwa (Weka Familia yenye mgonjwa wa TB/DR-TB Familia isiyo na mgonjw Mkusanyiko wa watu/sehem Mgang a wa jadi Matokeo ya mahojiano *Dalili alizonazo KH D H KU KJ Hana dalili Jina la kituo cha tiba alichopewa rufaa Matokeo ya rufaa (angalia kielelezo B Maoni * KH= Kikihozi. D= Makohozi yaliyochanganyika na Damu, H= Homa, KU= Kupungua uzito, KJ = Kutokwa jasho jingi kuliko kawaida hasa nyakati za usiku Kielelezo A: Kielelezo B: 1.Shule 5.Duka la Dawa 1.Hana TB 2.Nyumba za Ibada 6.Magereza 2.TB kwenye makohozi 3.Machimbo 7. Waganga wa tiba asilia 3.TB sehemu nyingine 4.Mikutano ya hadhara 8. Mengineyo (jata) 4.Rufaa haijafanikiwa

12 TB 15 WIZARA YA AFYA, MAENDELEO YA JAMI, JINSIA, WAZEE NA WATOTO Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma (NTLP) (Huduma shirikishi za TB, TB/UKIMWI na TB Sugu katika jamii) Fomu ya rufaa. 1. Sehemu hii ijazwe na Mwanakikundi wa kikundi cha waliougua na kupona TB au TB sugu nk. Jina la mgonjwa( Majina matatu) Umri(Miaka). Tarehe ya rufaa (Siku,Mwezi, Mwaka) / / Rufaa kutoka Jina la Kikundi Jina la mtoa rufaa Namba ya HUWANYU. Namba ya CTC.. Jinsi o Me o Ke Rufaa kwenda Jina la kituo cha tiba... Wilaya: Namba ya mtoa rufaa Namba ya simu. Sehemu nyingine (Shirika/taasisi) Jina.... Dalili za TB (Tiki panapohusika) o Kikohozi zaidi ya wiki mbili o Homa zaidi ya wiki mbili o Kupungua uzito o Kutokwa na jasho usiku zaidi ya wiki mbili o Maumivu ya Kifua o Kukohoa makohozi yenye mchanganyiko na damu. Zingatia: o Uchunguzi na matibabu ya TB na TB sugu hutolewa bila malipo. o Kwa WAVIU ni kikohozi cha muda wowote 2. Sehemu hii ijazwe na mtoa huduma wa kituo cha tiba. Jina la Kituo cha Tiba Jina la mteja. Tarehe ya kupokelewa mgonjwa.(siku,mwezi,mwaka) / / Huduma ya ugunduzi iliyotolewa. o Upimaji wa makohozi o Upimaji wa VVU o X-ray o Upimaji wa daktari (Physical examination) Matokeo ya vipimo o Kuwepo kwa vimelea vya TB o Hakuna vimelea o Kifua kikuu nje ya mapafu

13 Wizara ya Afya, Maendeleo ya Jamii, Jinsia, Wazee na Watoto Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma TB 13 A REJESTA YA WANAOHISIWA KUWA NA TB/DR-TB KATIKA JAMII Jina la kikundi/asasi/ Mtoa huduma za afya ngazi ya jamii: Na Tarehe Jina (majina matatu) Jinsi (Me/Ke) Umri (Miaka) Mahali alipotokea mteja/alipo hojiwa (Kielezo A) Makazi (Mtaa/kitongoji; namba ya simu kwa chini) Sababu ya rufaa (Kupima makohozi; Kurudi kwenye matibabu; Kupima VVU; Mengineyo) Jina la kituo cha tiba alichopewa rufaa Hana TB Matokeo ya rufaa (weka panapohusika) TB kwenye makohozi TB sehemu nyingine Amepima VVU (weka N kama jibu ni ndiyo, H kama jibu ni hapana) Ameanza tiba ya TB (weka kama ameanza na namba ya TB/DR-TB kwa chini) Matokeo ya matibabu kulingana na rejesta ya kituo cha tiba (TB03/ DR- TB04) Maoni/ Maelezo mengine Kielelezo A: 1 Familia yenye mgonjwa wa TB/DR-TB (Andika namba ya wilaya ya mgonjwa wa TB/DR-TB 2 Familia isiyo na mgonjwa wa TB/DR-TB 3 Mkusanyiko wa watu/sehemu nyingine (weka namba, Taja kama ilivyoandikwa kwenye fomu ya TB 14) 4 Mganga wa jadi

14 Wizara ya Afya, Maendeleo ya Jamii, Jinsia, Wazee na Watoto Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma TB 13 B REJESTA YA WAGONJWA WA TB/DR-TB WALIOKATISHA/WASIOANZA MATIBABU Jina la kikundi/asasi/ Mtoa huduma za afya ngazi ya jamii: Na. 1 Tarehe ya ufuatiliaji Jina (majina matatu), chini andika ya namba TB/ DR TB ya wilaya ya mgonjwa kama alianza matibabu Jinsi (Me/Ke) Umri (Miaka) Sifa ya mgonjwa anayefuatiliwa (Weka alama ya Vema panapohusika) Ameanza matibabu ya TB/DR TB Hajaanza matibabu ya TB/DR TB Mahali alipotokea mteja/alipohojiwa Mtaa/ Kijiji Balozi/ Mwenyekiti wa mtaa/kijiji Namba ya simu ya ndugu/mtu wa karibu Matokeo ya ufuatiliaji (weka alama ya Vema panapohusika) Amepatikana Hajapatikana Amefariki Amerudi Kama kwenye hapana, toa matibabu (ndio sababu au hapana) Maoni/ Maelezo mengine

15 M&E: Data collection and data flow structure ETL (Case Based)/ DHIS2 TB 03 (Unit Register) Community referral - from CHWs (Form TB15) Self Referrals

16 TB treatment card (TB01 which feed TB03) Wizara ya Afya na Usitawi wa Jamii Mpango wa Taifa wa Kudhibiti Kifua Kikuu na Ukoma TB 01 KADI YA MATIBABU YA KIFUA KIKUU Jina (Majina matatu): Anuani ya Makazi: Namba ya Wilaya Jina la Kituo cha Tiba Kiongozi wa mtaa/jirani: Namba ya simu (kama ipo): Mahali pa matibabu Kituo cha Tiba Nyumbani Jinsi Mme Mke Umri (miaka) Aina ya Kifua Kikuu Aina ya Mgonjwa Pulmonary New Rufaa na: Binafsi Previously treated Jamii Relapse CTC Extra-pulmonary Site: Failure Nyingine (Taja) Lost to follow up Others (specify) Taarifa za Msimamizi wa Matibabu HIV Status*: Pos Neg Jina la msimamizi wa matibabu: Anuani ya Makazi: Namba ya simu ya msimamizi wa matiababu: HIV Care Registration No: Haijulikani Uhusiano na mgonjwa Mwenzi CPT Ndiyo Start date No Mwanafamiliya Pre ART car Ndiyo Start date No Jirani/Rafiki ART drugs Ndiyo Start date No Mfanyakazi ngazi ya Jamii Nyingine (Taja) * HIV status: Pos: Positive, Neg: Negative

17 M&E... Data systems (status of DHIS2 adoption) Well functioning countrywide Reentry modified to case based system Data elements collected Notification by type of a patient, by sex, by age TB/HV data Referral status (from community/ self) Patients transfer Treatment outcome

18 M&E... Community TB indicators in DHIS2: Number of referred Presumptive TB cases from community Number of TB cases notified from community referrals (all forms) Number of bacteriological confirmed TB case notified from community referrals Number of TB patients under Home Based DOT Number of TB patients under HBDOT successfully treated Geographic coverage of monitoring and evaluation and related tools is uniform countrywide

19 Integrated TB service delivery Commu nity leaders HFs Community Other sectors CSO Services linked to other sectors in the community; linked to other health plans and interventions such as Chronic Lung diseases (NHL) Comprehensive monitoring and supervision visits have proven to be efficient However, there is a need to strengthen coordination of stakeholders engaged in the community

20 Mechanisms for coordination of community based TB activities Availability of Formal coordination mechanism e.g. NTP-NGO coordination body o Established recently through EANNASO under Stop TB partnership support Tanzania community TB Forum Key functions of the forum o Oversee implementation of Community TB care intervention and advocate to for improvement o TB Community voice How frequent are their meetings o Annually (last meeting 2017 for establishment) supported by EANNASO under stop TB partnerships, Any funding support? o Global Fund

21 Challenges, Bottlenecks and Solution Challenges/ Bottlenecks Solution Coordination Service delivery Monitoring and evaluation Inadequate Funds Lack of transparence (Some partners) Difficult referrals and treatment support, and follow up of homeless community Linking community TB data with the system (TB03: TB unit register) in some of HFs is still a problem. Fund mobilization for regular Coordination meetings Peer groups Regular supportive supervision and mentorship Involvement of DOT providers during community TB quarterly meetings in each BMU.

22 Success story: model for community based TB activities suitable for nationwide scale-up Sputum fixers in Kondoa District (Rashid Gora) This is a Community person trained in 2016 as a sputum fixers under GF support. He is working with almost five dispensaries and their catchment area for sputum collection, smear, fixing and transport the slides to Kondoa district hospital for TB diagnosis In 2017, Gora ( just one sputum fixers) had contributed 59 TB case in the country equivalent to 0.09% and 12% in Kondoa district. Lesson leant: Investment in Sputum fixers can increase much

23 Success story model for community based TB activities suitable for nationwide scale-up

24 TB CASES ATTRIBUTED FROM COMMUNITY REFFERRALS (%) Results Tremendous increase of community contribution in TB case notification in Global Fund supported regions from ) 20% 15% 10% 6% 7% 10% 5% 6% 4% 10% 6% 15% 15% 15% 11% 10% 9% 20% 15% 8% 10% 16% 14% 5% 0% Q Q Q Q Q Q Q Q PERIODS: GF supported regions National coverage Treatment success = 90% National coverage Treatment success : Home Based DOT 91.1% Defaulter 2% and Death 2%

25 Country work plans for community based TB activities Stated objective/ Module Key stakeholders for implementation Geographic coverage/stakehold ers Percentage of TB BMUs covered by current GF grant TB care and Prevention Community TB delivery NTLP NTLP/ AMREF 3 regions (Rukwa, Kigoma, Katavi) 8 regions (Dodoma, Shinyanga, Ruvuma, Kagera, Mbeya, Simiyu, Mara, Tanga) 72 BMUs / 208 BMUs (35%)

26 Country specific opportunities Opportunities to increase community engagement to achieve targets listed on previous slide Formalization of Community Health Worker cadre The country Plan is to have 2 CHWs per village (20,000 villages countrywide) Presence of willing CSOs to engage TB control activities in the country Recent modification of Electronic TB and Leprosy system to be case based. This will increase data verification concerning community referrals

27 Anticipated implementation challenges and suggested solutions Anticipated challenges Delay of implementation PR2 (First quarter No implementation) Duplication of efforts among stakeholders Suggested solutions PR2 to immediately start implementation Enhanced coordination at the National level and proper planning

28 Thank you