DECENTRALISED CARE FOR DR-TB: A complex disease requiring a comprehensive health system response Marian Loveday Presentation at FIDSSA Conference 7 November 2015
OUTLINE OF PRESENTATION Background DR-TB a complex disease Patient journey Decentralised vs centralised care Recommendations for effective care
South Africa: Nos of DS-TB and DR-TB: 2007-2014 450000 400000 DS-TB DR-TB 350000 300000 250000 200000 150000 100000 50000 0
PROVINCE 2009 2010 2011 2012 2013 2014 Eastern Cape 749 954 1170 1124 2041 1795 Free State 175 248 346 543 615 595 Gauteng 505 554 574 523 652 985 KwaZulu- Natal Number of DR-TB patients treated in South Africa Table 1: MDR TB cases started on 1597 2030 2370 3012 3717 3953 Limpopo 123 169 237 275 Partner 435 516 logo Mpumalanga 197 289 387 571 768 1094 North West 181 196 296 389 491 543 Northern Cape 227 308 282 287 333 336 Western Cape 1272 1629 1745 1529 1639 1760 South Africa 5026 6377 7407 8253 10691 11577
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
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
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 2008 30 June 2012) Primary outcomes Treatment outcomes and survival time
Decentralised MDR-TB management in KwaZulu-Natal: Comparison with treatment in a centralised setting Site 2 Site 4 Site 1 Centralised Hospital Site 3
BASELINE CHARACTERISTICS: DECENTRALISED VERSUS CENTRALISED SITES: 1 JULY 2008 31 JULY 2012
TREATMENT OUTCOMES: DECENTRALISED VERSUS CENTRALISED SITES: 1 JULY 2008 31 JULY 2012
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)
TREATMENT OUTCOMES AT THE 4 DECENTRALISED SITES
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
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.
Total health systems performance score per site
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)
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)
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
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