Current status of - WHO · Community Health Volunteers (CHVs) 205 townships of 15 States/ Regions...
Transcript of Current status of - WHO · Community Health Volunteers (CHVs) 205 townships of 15 States/ Regions...
Current status of Integrated Community Based TB Service Delivery &
Global Fund Work Plan To Find Missing TB cases
In Myanmar
Background
TB Situation in Myanmar
TB is a major public health problem
One of the world’s 30 high TB burden countries
30 high MDR-TB burden countries
30 high TB/HIV burden countries
Source: Global TB Report (2017) Rate (per 100,000 population)
Estimated incidence 361
Estimated TB Mortality (excludes HIV+TB)
47
Estimate TB Mortality (HIV+TB only) 9.3
Estimate Incidence (MDR/RR-TB) 25
MDR-TB among new TB patients (3rd DRS, 2012-2013)
5.0%
Milestones of Community Based TB Care Activities
• In 2007, with the support of 3DF, implementing partners started the community based
TB care activities in selected townships. No reports received in NTP.
• Draft guideline for community based TB care developed together with implementing
partners and technical support of WHO as an out put of workshop conducted on (4-9-
2010). Revised guideline on 2014 (English version) and 2015( Myanmar version).
• JICA implemented the pilot project for Community Based TB Care Activities in
Pyinmana Township
• To improve TB control activities in unreached areas, NTP is engaging with Local
NGOs in Community Based Care Activities in 2011. Community Based TB Care
Activities are starting since 2nd Quarter 2011.
• TOT training given to 4 local NGOs in Naypyitaw in 2011. Refresher training also
given every 2-3yr.
• Yet, the four local NGOs ; MMCWA, MWAF , MRCS and MHAA are implementing the
Community Based TB Care Activities in States and Regions.
8-03-17 4
ROLE & OBJECTIVES OF CBTBC
General Objective
• Involvement of community in TB prevention and care activities for reduction of TB disease burden in community
Specific Objectives
• To improve TB case finding
• To empower community for health thr: TB care
• To improve case holding
• To increase community awareness about TB
National coverage of community based TB activities
Year No. of townships with CBTBC
(*for township under TB funding scheme)
No. of reported
townships
Percentage of townships with
CBTBC
2014 201 319 63%
2015 221 319 69%
2016 235 320 73%
2017 276 321 85%
2018 242 321 75%
Key stakeholders for implementation
Local NGOs International NGOs
Myanmar Women’s Affairs Federation Asia Harm Reduction Network
Myanmar Maternal & Child Welfare Association
International Organization for Migration
Myanmar Medical Association International Union Against Tuberculosis and Lung Disease
Myanmar Health Assistants Association Malteser International
Myanmar Red Cross Society Medical Action Myanmar
Pyi Gyi Khin Population Services International
Ethnic Health Organizations (EHOs) World Vision International
Karen Department of Health and Welfare
Health Poverty Action
EHO – Special Region 2 Burnet Institute
EHO – Special Region 4 RIT/ JATA (Japan Anti-Tuberculosis Ass.)
Community Partners International
Geographical Coverage of stakeholders (2018)
Stakeholders No. of townships
Local NGOs Total 170 townships of 13 states/ Regions
International NGOs Total 166 townships of 15 States/ Regions
Both Local NGOs & INGOs Total 242 townships of 15 States/ Regions
Total 178 townships of Naypyitaw and 13 States/Region (55%) are covered by current GF grant.
Key community stakeholders with coverage
Implementation & Integrated TB Service Delivery
Activity Responsible Organization/ Person
Conduct situational analysis Implementing Partners (IPs)
Establish partnership & coordination mechanism
Township health committee & IP/all stakeholders
Capacity building
Dissemination of training materials NTP at Region/State level
Training NGOs, Township health staff with technical support from NTP
Infection Control All health workers
Advocacy, Communication & Social Mobilization
Key stakeholders, NTP, TMO, IPs
Supervision and M&E
Organize CBTBC team Led by TMO, IPs & local authorities
Regular S&M Joint supervision, NTP, TMO and IPs
Quarterly Review Meeting TMO, BHS, TB Coordinators, Volunteers, focal from IPs and local authorities
Implementing cadres and their geographical coverage
Cadres Geographical coverage in 2018
Community Health Volunteers (CHVs) 205 townships of 15 States/ Regions
Integrated Community Malaria Volunteers (ICMV)
48 townships of 4 States and 3 Regions
MDR-TB treatment supporter 65 townships of 3 States and 5 Regions
Drug seller 50 townships of 1 State and 6 Regions
Salary, Incentives and Other enablers
• Transport allowances and/or incentive payments for specific results
(referrals, notifications, treatment success)
• Financial incentives for DOT provision especially in CB MDR-TB Care
• Regular meetings and training & certificate of appreciation
• logistical support for volunteers such as health education materials,
infection control tools and implementation tools
• Recognition, acknowledgement and motivation by service
Referral mechanism of presumptive TB
Health talk in the
community
(special outreach program)
Identify presumptive
TB cases
Refer to township TB center (or)
sputum collection & transportation to
township TB center
- Diagnosed TB cases registered at township TB center
- DOT provision by volunteer
Implementation Tools
NTP Field level
Sputum request form Township CHV register
Township TB laboratory register TB Presumptive referral form from CHV to Township Health Centre
Tuberculosis Treatment Card TB register for CHV
Township TB Register Monthly report form for CHV
Quarterly report on TB registration [TB-07]
Monthly report form for Supervisor on CHV
Quarterly report on the outcomes of TB patients [TB-08]
Supervisor registry form
Monitoring and Evaluation
Monitoring and Evaluation
• Myanmar adopted WHO recommended core indicators.
• Standard & Benchmark analysis on TB Surveillance was done in collaboration with WHO and RIT in 2014 and 2017, showing the progress of the system.
• In 2014, MoHS began using DHIS2 for processing its data at the national level. Currently all township level data are entered at State/Region level. NTP planned to expand to the township level in 2nd quarter 2018.
• However, paper base system with aggregated data is still a main reliable tool to develop quarterly and annual TB report though DHIS2 began to function to have basic TB information in parallel.
Monthly Reporting
Monthly Reporting
Quarterly Reporting
Quarterly Reporting
Data collection & flow structure
CHV supervisor
CHVs CHVs
Township NTP/THD
CHVs
Central NTP
State/Regional NTP
Data Elements collected Number of townships adopting CBTBC
Number of CHVs trained in the program
Number of CHVs actively involved in the program
Number of presumptive TB referred by CHVs
Number of TB cases (all form) notified among presumptive cases
Number of TB patient receiving DOT through CHVs
Number of TB patients who received patient support
Number of patient completed TB treatment among patients availing DOT from CHVs
Number of HE sections and attendees
Number of supervision visit by community supervisor
INDICATORS
• Number of presumptive TB referral
• Number of all forms of TB cases notified from community based activities
• Percentage of notified TB cases (all forms) contributed by non-NTP providers – community referral
Success Story
Success Story: CBTBC model & outcomes
• A model for CBTBC was developed and piloted at Naypyitaw-Pyinmana Township, in collaboration with JICA project in 2011.
• After 18 months, the project showed good outcomes with regard to system development and case finding.
• For community-based TB care to be successful, not only commitment of CHVs in the communities but also the participation of all the health and administrative staff working for the communities together with community people are important.
SOURCE: Guideline for community based TB care to increase access to quality DOTS service , Myanmar, 2011
Success Story: Patient-Centered Community-based MDR-TB care &
treatment support model
• In 2015-2016, 3 Local NGOs implemented CB MDR TB care & provided evening DOT to 81% (1656/2053) of MDR TB patients in 37 townships of Yangon.
• CHVs provided HE and adherence counseling to patients & contacts, and referral services.
• Qualitative study showed that both patients and BHS appreciated adherence counseling & evening DOT, &
it was recommended to expand CB MDR TB care while HR at public health sector is limited.
[Saw et al., 2017]
RESULTS
Trend of National TB Case Notification (1994-2017)
17
41
0
21
16
1
24
16
2
27
44
8
30
16
4
36
54
1
40
24
4
42
58
8
41
24
8
41
38
9
42
31
8
42
33
2
42
91
0
42
59
5
50
18
8
48
82
5
51
41
6
49
55
0
18
44
4 29
18
6 43
80
2 56
89
1
65
85
3
77
21
9
81
82
8
78
48
1
82
89
3
84
81
6
89
81
5
93
54
4
87
40
6
91
82
4
91
87
5
88
20
9
82
47
5
15
55
17
00
8
20
19
6
16
11
3
14
75
6
19
62
6
31
70
3
42
45
5 5
82
43
77
23
1
97
90
9
10
79
91
12
35
93
13
35
47
12
87
39
13
40
23
13
74
03
14
31
64
14
81
49
14
21
62
14
20
12
14
07
00
13
96
25
13
20
25
0
20000
40000
60000
80000
100000
120000
140000
160000
No
. of
TB P
atie
nts
Years
Bacteriologically Confirmed Cases Clinically Diagnosed Cases Total TB Cases
Trend of CNR (2011-2017)
286 293 279 276 271 266
250
98 98 97 97 94 98 93
280 272 258 249
217 207
192
-
50
100
150
200
250
300
350
2011 2012 2013 2014 2015 2016 2017
Cas
e N
oti
fica
tio
n R
ate
pe
r 1
00
,00
0
CNR (all form) CNR (bact. Confirmed) CNR all forms by routine PCF
Contribution of community referral to national TB notification
1% 6% 6% 7% 11% 14% 15%
0
20000
40000
60000
80000
100000
120000
140000
160000
2011 2012 2013 2014 2015 2016 2017
No
. of
All
form
s o
f TB
pat
ien
ts
Year
National (NTP + Other units) Community partners
22% 18% 22% 17% 15% 16% 14%
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
2011 2012 2013 2014 2015 2016 2017
All forms of TB Referral of CHVs
All forms of TB among presumptive TB referral of Community Health Volunteers
Proportion of Total TB cases contributed by NTP & Other Partners
(2017) (n=132,025)
NTP 85%
Local NGOs 5%
INGOs 10%
NTP
Local NGOs
INGOs
Country work plans for community based TB activities
Country work plans for community based TB activities
1. Policy and strengthening CBTBC Timeline Responsibility
a. National level policy development 2011 (guidelines)
MOHS (NTP)
b. National and local level advocacy meeting with stakeholders and political and health authorities
Annually NTP, Implementing partners
c. National level production of communication tools
Annually NTP, Implementing partners
d. CBTBC evaluation meeting Annually Implementing partners
Country work plans for community based TB activities
2. Capacity building Timeline Responsibility
a. National level consultation to review/endorse and get familiar with advocacy and communication plan and tools, HR development plan and tools and M&E indicators.
MOHS (NTP)
b. National level printing of training materials (with periodic revisions)
Annually NTP, Implementing partners
c. Training Annually for New & Refresher
NTP, Implementing partners
d. Systematic recording and reporting of the activities.
Quarterly State/Regional/township NTP, Implementing partners
Country work plans for community based TB activities
3. Support to community health workers and volunteers
Timeline Responsibility
a. Establishment of self-help groups and village-based support groups
Implementing partners
b. Provision of incentives for delivering services by CHW.
Annually NTP, Implementing partners
c. Engagement of volunteers in health talks, contact tracing, sputum transportation, presumptive TB case referral and DOT provision
Annually NTP, Implementing partners
d. Quarterly evaluation meeting with volunteers
Quarterly State/Regional/township NTP, Implementing partners
Overall budget for community based TB activities
Module Budget (2018-2020)
TB care and prevention 17,396,647
MDR-TB 3,079,924
RSSH: Community responses and systems 948,063
RSSH: Health management information systems and M&E 5,068,968
RSSH: Human resources for health (HRH), including community health workers
5,644,394
RSSH: Integrated service delivery and quality improvement 28,902
RSSH: National health strategies 2,681,026
Total Budget 34,847,924
Country specific opportunities
o A very strong TB-TSG under MHSCC with its highly functional technical wings (working groups) ensures strong coordination and national ownership.
o Strong collaboration of National program, UN agencies and CSOs o Inclusion of Ethnic Health Organization in TB care and prevention
o Integration of community based TB services to ICMV volunteers*
through capacity building (*in local context where it is applicable)
o Epidemiological review for better implementation of CBTBC based on findings of ongoing prevalence survey
Implementation Challenges & Suggested Solutions
Limited Human Resource in public health sector, at all levels
HR support
Frequent turnover of IP staffs and community volunteers especially in highly mobile and border areas
Selection of strongly committed volunteers, Timely replacement and refresher trainings
Accessibility of diagnosis and cost for referral
Health services reachable to the communities eg; TB mobile clinics
Social protection programs or policies
Uneven distribution of NGOs & Coverage of CBTBC
mapping and avoid overlapping
Thank you
ADDITIONAL SLIDES
Coordination
• Most NGOs engaging TB service are members of TB Technical and Strategy Group (TBTSG) under Myanmar Health Sector Coordination Committee (M-HSCC, expanded version of CCM).
• WHO is a secretariat of TBTSG. More than 30 organizations are participating in TBTSG regularly. The meeting was held 3-4 times a year.
• Regular coordination and meeting was conducted between National Program, PRs and SRs.
• However, NGO coordinating body should be formed at regional and state, and township levels. Regular meeting in township level has been budgeted in GF project.
Mechanism for coordination of community-based TB activities
Implementation Tools: National Guidelines for CBTBC
Implementation Tools: Health Education flip chart
Support for implementation
1. NTP is supporting case finding of CBTBC
a. by strengthening resources and capacity at referral township centers
b. Disseminating guidelines for CBTBC and Training module
c. Supervision and monitoring
d. Joint supervision visits, and monitoring and evaluation of reports
2. Capacity building and refresher training annually
3. Supervision from supervisors/ upper level
4. Monthly/ Quarterly monitoring and annual evaluation of CBTBC activities
Implementation Tools: Presumptive TB Referral Form
Implementation Tools: Monthly Report Form for Community Health Volunteers
Implementation Tools: Monthly Report Form for Supervisor on CHVs
Implementation tool to ensure treatment completion and patient support:
Treatment Card