TB Reduction Among migrants in Thailand RAM Y1 Annual report.pdf · On top of the usual TB control...

TB RAM ANNUAL REPORT

Grant: THA-G06-T-08

October 2007-September 2008

Global Fund to fight AIDS, TB and Malaria (GFATM) Round 6

TB Reduction Among

migrants in Thailand

The content of this annual report is only a fraction of the results implemented in Year 1. Since the

project proposal began, the process of ensuring the grant commitment from GFATM until the first

disbursement to SRs had been a monumental effort for the new PR. Many staff had come and

gone due to the challenges faced in setting up this project and implement it effectively. Many staff

at PR and SR levels could not bear the workload and the dynamic of the project implementation as

well as the risks that the project carries. On top of the usual TB control project which requires

great understanding of the technical TB aspect, the project faces tremendous challenges by

implementing the TB control project among the non-Thai migrants who can be both legal and

illegal migrants living in Thailand. The cooperation of the government in providing the TB

technical expertise had been most valuable to the project implementation as we may not be able to

utilize all the health systems that had been set up for the Thai populations. The staff had to

convince the government and the business owners to allow access to work on TB control among

migrants using a community-based approach which is not the most common approach under Thai

NTP.

The results of this first year of implementation of identifying and helping almost 170 TB patients

under the project care has been a success for the PR and SR. Although the numbers may seem

small in comparison to the normal TB project in other countries, the efforts that had been put into

detecting the cases and help in achieving high sputum conversion rate of 93% had not been

minimal. On top of that, the TB RAM project had been awarded B1 and straight As from

GFATM since the second quarter of implementation. This has not been a minor success for the

new PR and for the SRs working in a hugely challenging situation.

The PR would like to acknowledge all the successes of the project to all levels of the PR and SR

staff that had started off, remained or had departed from the project. Their dedication had

contributed to the project success at any levels and are recognized and whole-heartedly applauded.

The commitment of both SRs and their management team had also contributed to the success

especially when the PRs had asked and exploited their commitment and services to ensure that the

project runs smoothly and effectively.

Lastly, the PR would like to acknowledge the commitment of the migrant health volunteers and the

migrant communities and most importantly, the TB patients. Without their commitment and

contribution at the community level, this project would not have success stories to tell. Thank you.

PR-WVFT team

Acknowledgement

Acknowledgement 3

Acronym list 6

Project background 8

Project background: TB burden 12

Project goals and objectives 14

Project concept and strategy 15

Project implementation Year 1: constraints 18

Project implementation Year 1: TB data among migrants 20

Project implementation Year 1: TB RAM model 21

Project implementation Year 1: PPM 22

Project implementation Year 1: ACSM 23

Project results: PBF indicators 28

Project results: Table of PBF indicators by quarter 39

Lessons Learned 40

Success stories 41

Conclusion 46

Table of Content

ACSM Advocacy, Communication and Social Mobilization AFB Acid Fast Bacilli

AIDS Acquired Immune Deficiency Syndrome

ARC American Refugee Committee ART Antiretroviral therapy

ARV Anti-retroviral BCC Behavioral Change Communication

CBO Community-Based Organization CHV Community Health Volunteers

CPT Co-Trimoxazole Prophylaxis Treatment

CTBC Community TB Care DOTS Directly Observed Treatment Short course

DST Drug susceptibility testing

EQA External Quality Assurance FSN Frontline Social Net-worker

FGD Focus Group Discussion GO Governmental Organizations

HIV Human Immunodeficiency Virus IEC Information, Education, Communication

IDS Indicators Data Sheet

KAP Knowledge, Attitudes and Practices KII Key Informant Interview

MDR Multi Drug Resistant M&E Monitoring and Evaluation

MLO Migrant Liaison officer MHV Migrant Health Volunteer

MOPH Ministry of Public Health

NTP National TB control Program PBF Performance-Based Funding

PLA Participatory Learning and Action PMO Project Medical Officer

PPHO Provincial Public Health Office

PPS/PS Provincial Project Site/Project site PR Principal Recipient

PSM Procurement and Supply Management R & R Recording and Reporting

SDA Service delivery area SSDP Secondary Service Delivery Point

SOP Standard Operating Procedure

SR Sub-Recipient TB Tuberculosis

TB RAM TB Reduction Among Migrants (GFATM Round 6 project under PR-WVFT) TBT TB Technical Trainer

TOT Training of Trainers

TSR Treatment Success Rate

Acronym list

VCT Voluntary Counseling and Testing WHO World Health Organization

WVFT World Vision Foundation of Thailand

WVI World Vision International

Acronym list (continue)

TB Reduction Among Migrants (TB RAM) project is mainly a community-based TB control

project among Burmese migrant populations living on the border or adjacent border provinces

between Thailand and Myanmar. The TB RAM project is part of Thailand GFATM Round 6 TB

control project that divides the project into that under the responsibility of 2 PRs:

Department of Disease Control (DDC) and PR World Vision Foundation of Thailand.

Thailand’s relative prosperity has made it an attractive destination for migrants from neighboring

countries. Current health data available indicates that in areas where there is a concentration of

migrants, the transmission of communicable diseases, like TB, is intensified. The Royal Thai

Government has limited resources to assist the migrant population and is not able to fully meet

their socio-economic needs. The result is poor health indicators for the migrants as a group (Thai

MOPH Annual Report, 2005).

Non-Thai migrants are one of the

most important groups to target for

TB control due to growing numbers,

crowded living conditions, mobility,

and legal status in Thailand. They

represent a sizeable population of

approximately 2.5 million, principally

coming from neighboring TB high

burden countries: Myanmar (80%) and

Cambodia (10%). Typically living in

border regions, they work in fishing

and fishing industries along the coast

and garment factories in the north.

Large numbers of non-Thai migrant

sex workers are also found in the border regions. Since the majority of non-Thai migrants are

unregistered and illegal in Thailand, they are ineligible for government funded health care.

TB information on non-Thai migrants is lacking because Thailand’s Ministry of Labor only collects

statistics on its legal population; data is gathered on those migrants who have officially registered

for work. In registering with the Ministry of Labor, migrants are required to undergo an annual

medical examination and may then access health services. In 2002, 448,480 registered migrants

Project Background

completed this medical examination and approximately 500/100,000 non-Thai migrants

(2,272/448,480) were diagnosed as having tuberculosis.

In the project’s proposed six implementation areas, the number of migrants found to have TB (in

2006) is higher than the national statistics: about 930/100,000 or 1560/135,000. These numbers,

again, only reflect the situation of registered migrants. The worst situation in the 6 provinces was

in Maesot (Tak) in northwest Thailand adjacent to Myanmar. This is a heavily utilized border

crossing through which large numbers of migrants enter Thailand for only short periods of time in

order to access health care or temporary jobs. TB prevalence is particularly difficult to assess

because of the transient nature of the migrants in this area.

Increasing numbers of non-Thai migrants are not able to access adequate health care. According to

a World Vision survey conducted in tsunami

affected areas, the ratio of registered to unregistered

non-Thai migrants was about 1:1 (Isarabhakdi, P.,

2005). Preliminary data from the Ministry of Labor

for 2006 indicates that registration rates have

declined dramatically and the ratio of registered to

unregistered migrants is now closer to 1:10.

The number of migrants eligible to register in

Thailand is dependent upon government policy

which changes regularly in terms of: 1) the number

of provinces allowing migrant registration, 2) the

occupations permitted for migrants, 3) the duration

of the registration, and 4) the cost of registration and health fees. These policy fluctuations

together with high registration fees (100 USD/person/year) have resulted in dramatic variations in

the number of registered (i.e.legal) migrants in Thailand and may account for their declining

numbers.

Non-Thai migrants are a TB vulnerable population and their inability to access health care seems to

be rooted to their legal status in Thailand. With the influx of non-Thai migrants within its borders,

the Thai government does not have enough resources to respond to the needs of citizen and non-

citizen alike. Non-governmental organizations (NGOs) must coordinate with governmental

organizations (GOs) to fill the gap in Thailand’s communicable disease control and prevention

Project Background

Project background

programs, especially as it pertains to the non-Thai migrant.

Working with non-Thai migrants presents innumerable challenges. Due to cultural differences,

language barriers, mobility and uncertain legal status, migrants may have difficulty developing trust

in the local communities. The non-Thai migrant’s native country is not often sympathetic to issues

of the migrant; and this makes cross-border collaboration between governments and assistance

agencies additionally complicated (Clarke, M, WV, 2007). For a variety of reasons, non-Thai

migrants are in the unfortunate position of not being able to receive assistance in their own land

and of not being able to easily access assistance in Thailand. With the aforementioned obstacles in

mind, and recognizing the gravity of TB vulnerability among non-Thai migrants, this project aims

to focus on this population and their access to needed and deserved TB care.

Situation in Year 1

“During the first quarter, the rising fuel price has resulted in minor migration of labor groups to

both alternative industries and locations. Small-scale fishing enterprises have suffered from the

increasing fuel costs and therefore has had to tighten the labor roster to accommodate for the

increased fuel expenses. Migrants who were let go from their jobs tended to switch industries and

many have entered into shore jobs like agriculture and construction works, which have been

somewhat readily available in Phuket and Phang Nga provinces. Although this change in economic

and labor pattern have been noticeable in Southern provinces, the overall situation for migrant

laborers, and therefore project implementation context, have not been overly impacted in either a

positive or negative direction.

During the second quarter, fishing industry continued to get

worse, which caused the migrant laborers in the industry to

look for an alternative work on shore. Even though the

migrant policy in Thailand does not have an enabling

environment, the migration from Myanmar continued to

increase as Myanmar economy was in continual declining

phase.

During the third quarter, large number of Myanmar

migrants flocked to Thailand, escaping the deteriorating impact of Nargis Cyclone, throughout

many border points. Due to increased migration into Thailand from Myanmar, migrant labor

Project background: TB burden

market equilibrium changed to higher supply over demand giving rise to decline in job opportunity

and lower income for the migrants.

By the 4th quarter of year 1, the Global Financial Crisis had spread over the third-world countries

by reduction of export demands of US and its allied countries that reflected affecting the low-

income migrant communities with lower earning and job loss in many areas of business industry.”

TB burden among Thais and migrants

In 2005, the official population in Thailand was 66 million with an additional 2.5 million persons

from other countries also living in Thailand. Thailand is currently the 17th of 22 high-burden

countries (HBCs) that collectively account for 80% of TB cases globally. An estimated 30% of the

population has latent TB-infection. Annually, between 47,000 and 56,000 persons are diagnosed

with TB disease and reported to the NTP. However, the NTP receives reports (case-finding,

sputum conversion, and treatment outcomes) only from health services under the MOPH. Thus,

the actual number of cases of TB disease may be higher because of failure to diagnose or report TB

by MOPH or non-MOPH facilities, such as clinics or private hospitals.

According to the WHO Report 2008 (Thailand; Surveillance and Epidemiology, 2006):

• Estimated prevalence of all cases is 198/100,000 population

• Estimated incidence of all cases is 142/100,000 population

• Estimated incidence of smear positive cases is 62/100,000 population

• Estimated mortality rate for all cases is 20/100,000 population

• Of new TB cases, % HIV + is 11%

• Of new TB cases, % MDR TB is 1.7%

• Of previously treated TB cases, % MDR TB is 35%

Currently there is an uncertain number of TB burden among migrants in Thailand. As the mobility

of the migrants does not allow access nor surveillance to include the migrant populations in the

national Thai TB database, it is difficult to gauge the actual burden in the country.

Thailand MoPH-US Communicable Disease Collaboration (TUC) has carried out a study on

Project background: TB burden

selected provinces with high migrant populations on various border areas. The migrants TB

burden varies from province to province depending on the border crossings of the neighbouring

countries. From the national TB data, it is difficult to utilize the country’s prevalence/incidence or

the neighbouring countries prevalence or incidence to calculate the appropriate expected cases of

the migrants in Thailand.

The figure below shows the estimated TB case detection among non-Thai migrants in various

provinces in Thailand.

Figure left: Estimate TB case detection

among non-Thais by Bureau of Tuberculosis,

2007.

The high TB case detection estimated along the Thailand-Myanmar border showed that there is a

possibility of at least 300 cases/year in both Ranong and Tak province under the 6 provinces

catchment area of TB RAM project. Unfortunately, there is no other information available for the

migrants populations in the country as in some districts, the non-Thai information is not being

reported to the national level (Jittimanee S, et al. 2008).

Project goals & objectives

TB Reduction Among Migrant (TB RAM)

Goal: To reduce TB morbidity among non-Thai migrant in six border and adjacent provinces

Target Group/Beneficiaries:

• 135,000 direct target non-Thai migrants in six border and adjacent provinces

• 200,000 indirect target non-Thai migrants in six border and adjacent provinces

• 500,000 indirect target Thai populations in six border and adjacent provinces

Provinces WVFT ARC

Districts

Ranong Muang Kraburi

Phang Nga Kuraburi Takuatung

Takuapa

Taimuang

Phuket Muang

Katu

Chumporn Muang Tasae

Paknam lang-suan

Kanchanaburi Sangklaburi

Tongpapoom

Tak Maesot

Project goals & objectives

The six provinces include Ranong, Phang Nga, Phuket, Chumporn, Kanchanaburi, and Tak.

These provinces are the areas where both WVFT and ARC have previous experiences working on

disease control in previous projects such as GFATM Round 1 on TB and GFATM Round 2 on

HIV for WVFT or USAID Infections Disease control project by ARC.

Provinces are subdivided into districts. WVFT will concentrate on nine (9) districts and ARC will

concentrate on six (6). Although WVFT and ARC will each work in separate district areas, there

are 3 provinces in which WVFT and ARC will both be working and will coordinate their efforts in

these provinces (see table on the left).

The following four GF6 program objectives integrate the aforementioned NTP strategies as well as

WHO STOP TB strategy for the Western Pacific:

Objective 1: To expand quality TB services to increase case detection and treatment success

among non-Thai migrants

Objective 2: To develop a service delivery system that ensures coordinated TB care for non-Thai

migrants.

Objective 3: To empower non-Thai communities to reduce their TB burden through public

awareness and patient support.

Objective 4: To increase the capacity of WVFT and ARC to conduct TB control among non-Thai

migrants.

Following the WHO Strategic Plan to Stop TB framework (2006-2010), this project aims to

address the following issues through its interventions.

Strategies alignment to the National TB Programme:

There are four national strategies for TB management, formed by the National TB

Program (NTP) that WVFT and ARC have utilized in the GF6 program:

1. Establishment of TB Collaboration Mechanism for Border Areas for coordinated

TB care

Currently, a few provinces in Thailand have MoPH pilot sites that provide health services to the

Project concept and strategy

migrant populations. In these locations both NGOs and GOs are implementing health care

services to the target groups, and an informally coordinated TB care system has been established in

some areas. With the GF6 program, a formally coordinated TB care system will be established

between WVFT and/or ARC and the tertiary service delivery points within shared province,

Offices of Disease Prevention & Control and Provincial Public Health Offices.

2.Enhance TB management with participation of communities and all relevant

partners

Both WVFT and ARC will encourage community members, business owners, community leaders

and other relevant partners to participate in the project as a way to enhance effective TB

management. By encouraging their participation, the program hopes to increase patients’

adherence to care. Community volunteers and networks will be encouraged to carry out DOTS

and to be watch-groups for health-related issues which could then be adapted to other non-health

related issues for the communities. The strategy in community participation would also include the

Thai communities because migrant and Thai communities are integrated in the same areas. The

program cannot focus on the migrant communities alone, ignoring the host communities.

Community mobilization would then include both populations so as to create a peaceful and

cooperative environment. With support from the Thai Ministry of Public health system, and

capacity building assistance from GF6, the Thai community volunteers might also provide DOTS

to Thai TB patients.

3. Systematic Development of Human Capacity

As human resource capacity seems to be the main challenge in most organizations, the program

intends to establish a systematic development of human resource capacity through regular

trainings, workshops, on-the-job trainings, and regular performance feedback.

4. Promotion and Support of Research and Development

The program has been designed to carry out two (2) operational research activities to improve the

strategic management of the program. Through the course of the program, key issues of migrant

TB management will be identified as possible research topics. Research will then be conducted to

better understand the identified issues and the results will be used to improve upon migrant TB

management and care. Results will also be used to inform the NTP about the migrant situation in

Thailand.

Project concept and strategy

WHO Strategic Plan to Stop TB Framework

Pursue high-quality DOTS expansion and enhancement

• Political commitment (advocacy on TB awareness and forming of national steering

committee on TB among migrants to increase collaboration)

• Case detection through quality-assured bacteriology (using governmental facilities)

• Standardised treatment with supervision and patient support (following NTP

guidelines)

• An effective drug supply and management system (using government systems)

• Monitoring and evaluation system

Address TB-HIV, MDR-TB and other challenges

• Implement collaborative TB-HIV activities (provision of PITC to all TB patients

and refer those who need ARV to other NGOs providing)

• Prevent and control MDR-TB (provision of sputum culture to smear positive

patients who undergo retreatment)

Contribute to health system strengthening

• Improve human resources, financing, management, service delivery system and

information systems (training workshops for PR and SRs)

• Adapt innovations from other fields (using expertises and experiences from existing

migrant health-related projects and area development programs)

Engage all care providers

• Public-Private Mix (PPM) approaches (NGOs/GO approach)

• International Standards for Tuberculosis Care (ISTC)

Empower people with TB and communities

• Advocacy, communication and social mobilisation (training, forming of migrant

health volunteer networks, advocating community leaders, business owners, etc.)

• Community participation in TB care (engaging community leaders, business

owners, former successful TB patients to participate in care of new TB patients)

Project implementation in Year 1: constraints

Programme Implementation in Year 1

The community approach is the key strategy that WVFT adopted as it is also the mandate of WVI

strategy. The migrant setting, however, presented various challenges to provide the community-

based services to the communities as the communities are comprised of both legal and illegal

migrants. Health and disease issues have no nationality boundaries within the country and the

disease control among migrants is also being advocated at various levels to ensure a supportive

environment for health services access for migrant populations. As WVFT has extensive

experiences working with the Burmese migrants in the community in reproductive health, HIV

prevention and TB DOTS at the community level, the model has been adapted to apply to both

SRs to ensure expansion of quality community DOTS to the migrant communities.

WVFT model on ACSM DOT among migrant populations

WVFT model has been adapted from our own experience in the field during the GFATM Round 1

and Round 2 implementation on TB and HIV prevention at the community level. This figure

below (Figure ) explains the involvement of the NGOs in mobilizing the communities and the

government service providers to be engaged in migrant disease control by leveraging strengths

from different partners in the field.

Challenges to consider:

Language barrier

As the key challenge in disease control among migrants is the information access to both health

services and health information, language barrier has to be overcome to ensure equitable access to

all. Migrant Health Volunteers (MHVs) and Migrant Health Workers are the key players from the

communities that greatly contribute to the project implementation as they are from the same

communities with the similar social background to understand the situation of the target

beneficiaries. There are at least 3 main languages spoken by the target beneficiaries excluding Thai

language in accordance with the ethnic races of the migrants which are Karen, Burmese and

Mon. This also poses as an issue to the languages of the publications to be mass produced for the

target groups. However, as we had recruited the MHWs and MHVs, most of them speak the same

language as the target beneficiaries which will overcome the language barrier issue that the

government service providers had been experiencing. The written language is still a challenge for

the NGOs to solve in the subsequent years as the key language used in the written document is

Implementation in Year 1: Constraints

mainly Burmese in Phase 1.

Misconceptions

At the same time, from the baseline survey report, it appeared that there are many misconceptions

in TB diseases at the community level which need to be addressed. The best way to address

misconceptions is to have them communicated by the people who might have had the same

misconceptions to convince them of the correct messages. The languages used will be simpler than

the technical terms by the medical officers or at least will be understandable in the same language

medium.

Educational background

There is also a high percentage of illiteracy among the migrant populations in the catchment areas

(at least 26.5%) which make up to about a quarter of the population in which women contribute

mainly to this illiterate group. About another one third of the population has very basic level of

education (8% can read or write and 24% have primary school education). (TB RAM Baseline

survey, 2009) This information from TB RAM baseline survey corresponded with the previous

baseline survey within WVFT catchment areas from the previous reproductive health project in

2005 (Isarapakdi, P, 2005).

Coordination with gatekeepers

While working in the community, NGO staff and those involved should also understand that the

migrants priority is not in health or disease control. The migrants are in Thailand mainly for

economic reasons and therefore would spend most of their time working. In the first year of

implementation, patience is clearly needed to establish a trusting relationship with the communities,

the business owners, the government health servicer providers and most importantly, the

government law officers. Prior to the community entry, various steps had to be taken to ensure the

clear understanding between various stakeholders, most importantly the business owners and

government law officers and immigration officers. These stakeholders are called gatekeepers in the

migrant project. Without permission of the gatekeepers, it would be very difficult or impossible to

gain entry to the target groups. This process of creating the bonds of trust requires time and

dedication of the SRs and the bonds are initially fragile depending on many things such as a

political climate on the migrant standpoints by the government in each period.

Implementation in year 1: TB data for migrants

Mobility of the target groups

The mobility of the target group is the key challenge in following up the patient to start enrolling

for treatment and more importantly, to adhere to the treatment as required for at least 6 months.

The TB suspect once diagnosed with TB may be in Thailand on a temporary basis or move to

another part of the country for better occupational opportunities. Long discussions and intensive

health education is needed to convey the importance of TB treatment, the follow– up sessions and

the completion of the medication. This is a very difficult situation for the NGOs as a counselor to

the TB patients when the patients decide not to start the medication or to move away while under

treatment. Many adaptations and methods to assist the patients to continue the treatment had to

be devised to suit the migrants life-styles and needs. This confirms that TB is not just a public

health issue but clearly a social issue when it deals with the well-being of the patients and their

families that may depend on the patients’ strengths to feed them.

TB data calculation for migrants

As the migrants are currently the vulnerable populations in Thailand, disease-related information is

very limited as the government does not have the system that regularly collects and updates the

information at the national level. For the demographic data, the information from Ministry of

Labour was utilized, however, that only contained the registered migrants information and the

estimate number of migrant workers as required by the business owners. This demographic data is

therefore, can be relied on partially as it is estimated that there are currently about 3.5 times the

registered amount, compared to the registered migrants data recorded by Ministry of Labour.

Some TB-related information is collected by Bureau of Epidemiology on TB treatment but that is

also very limited when reviewing the data collected by the project.

Originally, the TB RAM project utilized the demographic data reported by the SRs in their

catchment area to calculate the population. Many options were considered to calculate the most

accurate TB-disease trend of migrants including the Thai prevalence, Myanmar prevalence, etc.

However, as TB RAM targets were revised during the grant negotiation period with very limited

time and no assistance from MoPH or WHO, the project staff decided to use the population data

from the SR field sites in combination with the Ministry of Labour registered migrants annual

health check-ups which include TB screening using chest x-ray (table shown below).

The Burmese registration ratio in comparison to all 3-nationalities registration (Burmese:

Cambodian plus Laotians) is then used to calculate the population make up in the migrant

Implementation in year 1: TB data for migrants

registration data (80:20) as the project catchment areas contain mostly Burmese migrants as the

areas are along the Thai-Burmese border.

As a result of the lack of TB information for the migrants population, the assumed prevalence was

calculated at about 977 all TB cases/100,000 population of migrants (see table below). TB RAM

project realized that most of the TB results from Ministry of Labour composed mostly of the

smear negative patients due to the method of radiography which could identify abnormalities in the

chest rather than the smear positivity or negativity of the patients. Therefore, the project used the

usual smear positive versus smear negative ratio of 50:50 to calculate the patients make-up in the

project.

Based on the calculation above, the TB RAM project targets were formulated for both Phase 1 &

2. This data was not confirmed by the TB experts and can be highly risky in the estimate of the

project targets and achievement and should be reviewed prior to Phase 2 renewal process.

TB control model in TB RAM project

The model illustrated below is a summary of the overall implementation of the TB RAM project.

All of the 4 objectives are included in this diagram to give a brief understanding of the project.

The model is divided into two STOP TB approaches: Public-Private Mix or Public-Public Mix

(PPM) in some areas and Advocacy, Communication, and Social Mobilisation (ACSM) DOT.

Implementation in year 1: PPM

Figure : TB control model in TB RAM project

Public-Private Mix or Public-Public Mix or Private-Private Mix (PPM) Approach

As mentioned before, the project emphasizes on leveraging the strengths of each partner in the TB

control among migrants, each stakeholders play different roles in the project through effective

collaboration and coordination. In the area of implementation, there are different levels of TB

stakeholders who provide different services on TB control. There are government hospitals,

private hospitals, primary health care units, NGO hospitals and NGOs. In this case, all the facility-

based service providers such as government, private or NGO hospitals will use their strengths in

terms of diagnosis and treatment of TB patients. Their long and established presence in the

community also enhance the health-seeking behaviour for the walk-in patients who were not aware

of the project in the area.

The hospitals would also have developed and perfected the 4 key elements of DOT e.g. utilisation

of microscopy for diagnosis, continuous drug supply, Recording and Reporting and Monitoring

and evaluation of the TB results. These are the key strengths in which the project may not be able

to assist in building the capacity as it mainly falls under the government responsibility of NTP or

the NGO hospitals.

Implementation in year 1: Acsm

In this case, the Public-Private Mix or Private-Private Mix would be the coordination between

Public government, private or NGO hospitals and the community-based NGOs or SRs of this

project. The SRs will assist in identifying TB suspects and cases to refer to the hospitals to receive

diagnosis and medication. The patients will also be recorded and reported through the existing

government channels as their patients . The hospitals would most of the time refer the patients

back to the SRs to continue following up with the patients for DOT as the SRs would have

identified the trained MHVs or other DOT partners in the community for the patients. This

setting applies to most areas of implementation within TB RAM project and requires good

coordination and regular collaboration with the hospitals to refer the patients.

In the aspects of Public-Public Mix, the SRs will utilize the government primary health care units

(PCUs) as their community base to refer the patients from the hospitals to be under the PCUs

responsibility. This has proven to be time-consuming in establishing the relationship as most

hospitals do not appear to utilize the easy-access PCUs for DOT follow-ups but tend to recruit

their own health workers in the hospitals to follow up the patients.

Advocacy, Communication and Social Mobilisation, Directly-Observed Treatment,

Short Course. (ACSM DOTS)

Advocacy at various levels

On the other side of the services, the SRs main strengths are at the community level. Many

activities concentrate on building the capacity of the migrant community members to create

community awareness and resilience to TB and HIV. The continuation of the GFATM Round 1

and Round 2 grants in SR-WVFT areas has been beneficial to the start-up of this TB RAM project

as the presence and the reputation had been recognized by the government and the communities in

their TB and HIV efforts in some provinces. ARC also had previous projects from the other

donor to implement an infectious disease control project in their areas of implementation.

However, as TB control is very crucial for the government and the involvement of the NGOs had

been rather limited at the community level, serious advocacy had to be carried out by the SRs and

the PR in the first year to ensure the efficiency of using ACSM-DOTS approach. The government

choices of DOT partners would be the government health staff to provide DOTS at the hospitals

while the TB RAM project would concentrate on increasing the community capacity to provide

DOTS at the community level to reduce travel time and hence increase treatment adherence while


aligning with the government procedures and treatment regimen. This has proven to be a

continuous struggle for the project for the whole of year 1 and continued to be a debate in Year 2

although NTP has a ACSM-DOTS policy in place (See Thailand National TB Programme Policy,

2005). Many provinces are still vary of the approach taken by this project although the letters had

been issued by Department of Disease Control requesting the collaboration by the provincial

offices and hospitals with both the SRs in 6 provinces in the second quarter of Year 1. TB RAM

continues to use an evidence-based advocacy to present results of successful implementation

(sputum conversion rate and treatment success) to both the national and provincial government

officials that the community can assist a successful TB control programme in alignment with the

government policy.

The PR’s role for advocacy is also the key strategy in ensuring policy implementation at various

levels as migrants are part of the NTP plan. Advocacy activities at the national level include

representing at the CCM and CCM Technical committee on TB to increase government’s

cooperation to include migrants health information to the existing TB system.

Identification of both existing and new MHVs and health workers was carried out in the first

quarters of the project and continued to expand in the subsequent quarters to reach more

communities in other areas. The process of volunteers identification usually involved discussions

with community leaders, natural leaders and/or business owners. The community leaders and

business owners would be advocated through informal meetings to understand TB issues and the

importance of TB control or the recruitment of volunteers. Successful advocacy stories in the first

year had been identified in the latter part of this report including the involvement of the business

owners building the community health posts for the migrant workers themselves in the

construction areas in Phuket (see Success stories).

Community TB care

After the volunteers identification process and partial success in advocating both the government

and local business owners in the communities, the rigorous recruitment and training of the

volunteers began in the community as soon as quarter 2. The original training materials were taken

from the experience and documents in Global Fund Round 1 (TB control among migrants) from

Ranong province for SR-WVFT. The Frontline Social Networks (FSNs) or the migrant health

workers for SR-WVFT would be trained by the TB Technical Trainers in Burmese in order to train

the Migrant Health Volunteers in the communities. For SR-ARC, the trainings were carried out

mainly by the government officials through the translation by their Thai-Burmese speaking health

workers. During the training sessions, many volunteers themselves asked to be screened for TB and

many had referred their neighbours or family members to be screened as they recognized TB signs

and symptoms. The number of TB suspect referrals started to appear in quarter 1 and increased

quarterly as the trainings progressed and the number of volunteers increased. At the end of year 1,

most volunteers were trained more than once to refresh the information in order to become DOT

partners.

The challenge of the migrant community-based TB care is mobility. Although TB RAM may have

trained a large number of volunteers in the community, there is also a high turnover rate of those

previously trained. The actual percentage of turnover of the volunteers has not yet been calculated

but roughly only 50% of the initial trainees received refresher trainings in the same year.

Unexpected challenge: DOT Partners and their migrant legal status

Migrant legal status, their mobility and the turnover of the volunteers trained have resulted in the

selection of DOT partners once the patients had been identified. Initially, the project planned to

adhere to WHO guideline as much as possible to use non-family members as DOT partners. In

reality, many DOT partners are not the trained Migrant Health Volunteers (MHVs) but were relatives

or neighbours who lived nearby patients’ homes. Despite this development, they were all trained

intensively by the Migrant Health Workers before treatment began to enable them to become effective

treatment providers. In year 1, there were about more than 50% trained volunteers acting as DOT

partners. There were also a high percentage of relatives and FSN/MLO who are migrant health

workers providing treatment to the patients in the community at 26% and 17% respectively.


55%26%

2% 17%

Year 1 DOT Partners ratio

MHV Relatives Neighbours FSN/MLO

Figure on the right: Burmese Migrant Health Workers

(FSNs) follow up their patients with a bicycle during a rainy

season in Maesot (Tak province).

There were various discussions regarding the choices of the DOT partners and the distance or legal

status or mobility restriction of the migrants seemed to be the key factors in choosing the suitable

DOT partners for the patients. Many volunteers do not have registration cards and therefore are

restricted to moving freely for fear of being caught. In this case, either the relatives/neighbours or

migrant health workers have to assist in providing treatment. The relatives or neighbours would have

an easy access to the patients while the FSN/MLOs can travel more freely as they are either registered

migrants or Thai community health volunteers. This has become a challenge for the implementing

team to select the suitable volunteers as DOT partners due to lack of registration cards. Sometimes

DOT partners also have to accompany the patients to the monthly hospital visits to receive check-ups

and medicines and this cannot be done due to their travel limitation as illegal migrants. In many cases,

the field staff, FSNs or MLOs have to assist the patients in providing transportation the routine

hospital trips to negotiate with the police officers during the travel period or to assist in translation at

the hospitals due to language barrier. This increases the workload of the FSNs/MLOs in their roles in

monitoring the volunteers and DOT partners work.

Community Health Posts (CHP)

As part of the community mobilization, the project used the community health post model from

WVFT previous project on reproductive health funded by UNFPA in the migrant populations in

Ranong. Community Health Posts from the UNFPA project served as a meeting point between

migrant community members and their volunteers utilizing the Thai Community Health Volunteers

houses to set up. The aim was to ensure community harmonization between the host communities

and the migrant communities as sometimes migrants were perceived as a threat or maybe looked

down upon. Migrant Health Volunteers also moved quite frequently and by using the Thai

Community Health Volunteers’ residence as health posts, it should enable the community to locate

the facilities a little easier in comparison to the MHVs’ homes. The Community Health Posts served

many purposes which may or may not include all these functions in one health posts. The purposes

served are: information centre for TB and other health-related information, meeting points for MHVs

and TB network groups, sputum collection points for suspects, suspect referral points, health

education meeting areas, recreational areas for the communities such as acting as libraries. In some

cases where there are no Thai CHVs houses available, MHVs houses act as Community Health Posts

instead.

Many suspects were referred from the Community Health Posts set up in the communities as a result

of year 1 implementation.

Project Results: Ten key indicators

In Phase 1, there are 10 output indicators that the PR has committed with GFATM that are related to

the project design, both objectives and Service Delivery Areas (SDAs). These indicators are reported

either as cumulative annually or non-cumulative results.

PBF indicator 1.1: Case detection number of new smear positive TB patients

(cumulative annually)

In Phase 1 although there is no reliable TB-related information existing for the calculation of TB

among migrants, TB RAM project used the assumed prevalence of 977/100,000 population/year of

the TB disease among migrants explained earlier. This has been used as a basis to calculate Phase 1

and Phase 2 number of cases to be detected and enrolled. The plan in Year 1 has been formulated as

a preparation period for the project in order to build staff capacity and empower the communities on

TB information. The community was trained through Migrant Health Volunteers and Migrant Health

Workers (FSN/MLO) From the results in Year one, many cases were detected even in Quarters 1

and 2 in WVFT Ranong province, as the province has been implementing on GFATM Round 1 on

TB and is equipped with well-trained FSNs on TB. Since the first quarter, more cases had been

detected mainly through 4 means: hospital referral, FSN/MLO, walk-in patients, and community

referrals. The total number of new smear positive TB patients detected in Year 1 is 113 cases among

168 all cases detected.

It is interesting to notice the ratio of smear positive and other TB cases among this group of migrant

patients detected in Year 1. The ratio is 68:23:9 (sm+:sm-:EP) as seen in the pie chart demonstrated.

It may possibly to deduce that since this is the first year of implementation, many patients may have

had a prolonged symptom of TB prior to detection. This might have resulted in a much higher smear

positive cases compared to the Thai nationals as reported by Bureau of Tuberculosis between 2001-

2005 at the ratio of about 50:30:15 (see the bar graph). We could probably expect the percentage of

the ratio between smear positive and other TB cases to be more similar to the Thai nationals in the

subsequent years.

0

20

40

60

80

100

120

1 2 3 4

No. of cases

Quarters

Case detection for Year I

Plan

Figure above: A pie chart demonstrating both number and percentage of migrant TB cases as detected by TB RAM project

in Year 1.

Figure above: Percentage of male and female migrant TB patients in TB RAM Year 1. The ratio is similar to the Thai

nationals of 2:1.

Figure above: A bar chart demonstrating the proportion of Thai TB cases detected in 2001-2005. The chart shows a constant

rate of about 50:50 (new Sm+ ratio to others).

Smear(+)

64%

Relapse

4%

Smear(-)

23%

EP

9%

Percentage of all cases detected in Year 1

Smear(+)

Relapse

Smear(-)

EP

Male

65%

Female

35%

Percentage of male and female migrant TB

patients in Year 1

Male

Female

PBF indicator 1.2: Treatment enrollment number of new smear positive TB patients


An overall number of 93% of all detected new-smear positive cases were enrolled for treatment in

Year I. As more cases were detected, more cases were enrolled then planned. For Q1, 1 out of 1

patient enrolled, Q2 32 out of 32 patients enrolled, Q3 71 out of 74 patients enrolled and in Q4 106

out of 113 patients were enrolled. The original plan only aimed at less than 80% of all smear positive

cases detected to be enrolled for treatment due to the preparation period of the project. The plan

aimed to build the capacity of the TB counselors or the project staff and volunteers in understanding

the importance of TB treatment and more importantly, treatment adherence of the patients. From the

experience in GFATM Round 1, the FSNs had provided an intensive pre– and post-test TB

counseling to the patients explaining the importance of treatment completion to ensure treatment

adherence for the whole period of medication as well as exploring several issues regarding treatment

adherence that the patients could encounter. The MHVs and/or DOT partners were also trained in

TB counseling to patients on the following topics:

• Duration of treatment

• Drugs regimen and combination

• Minor and major side-effects of the drugs

• Dates of sputum follow-ups

• Risk of mobility and importance of treatment compliance to reduce the development of

MDR-TB.

Many issues were identified from the counseling sessions such as employment requirements for

fishermen to leave the mainland and stay on the boat for many weeks or months which could disrupt

the patients DOTS adherence. Sometimes occupation counseling was also required to seek other

Enrolment of new smear positive TB cases of Year I

0

20

40

60

80

100

120

1 2 3 4

Quarters

No. of cases

Plan

Actual

possibilities to assist the patients in looking for a new job while undergoing the intensive phase of

treatment or the whole 6-9 months duration. In the first two quarters, most of the patients enrolled

were in Ranong province where the trained FSNs could provide an effective TB counseling to the

patients identified in the provinces. In other provinces, the TB Technical Trainers (Burmese speaking)

or the government health service providers (with Burmese translation) were providing counseling to

the patients prior to their treatment commencement.

As a result, there were at least 7% primary defaults among the detected cases. This has been a

constant discussion with Bureau of TB as the government (and WHO) strongly believes in providing

treatment for all cases. As for the TB RAM project, this has also been an internal argument among

the project staff as to which is more important, the possibility of the detected case infecting their

friends and neighbours or the possibility of creating MDR-TB cases in the patients who will not be

able to continue their treatment due to their occupational requirements. From some informal

discussions with the project staff, many issues had been identified as the key factors for primary

defaults or even the treatment adherence.

• Income or loss of income

• Patients’ awareness on TB treatment

• Patient’s initial fear of drugs side-effects which could lead to temporary loss of jobs or income

• Stigma on TB which could be related to stigma in having DOTS partners

• Severe or late stages HIV infection—delay treatment decision from the medical doctors

• Lack of trained DOT partners in the patients’ neighbourhood

Many of these issues had not been discussed at lengths with the SR project staff to find the solutions

to solve the primary default problems. There are certain facts regarding the migrant target groups that

could be the factors of primary defaults: 1) they are of working age group as 80% are under 40 years

old (TB RAM Baseline survey report, 2008) and 2) Most of the patients detected are male migrant

workers (65%). These two factors would increase the aversion of having a prolonged treatment that

could affect their daily income especially if the treatment also has severe side-effects and can cause

suspicions with the business owners or the landlords/landladies if the stigma reduction process has

not reached the satisfactory level yet. During GFATM Round 1, some patients were expelled from

the house by their own spouses and could not reveal themselves as TB positive in the community.

For GFATM Round 6, the project only started implementing for 1 year and stigma is still high among

community members for the lack of correct information on TB transmission.

However, the importance and the clarity of messages during the pre-treatment counseling should be

addressed to reduce primary defaults. More community-based advocacy and business owners

advocacy are also required to reduce stigma among community members and increase the business

owners awareness to assist in TB control and treatment adherence of their migrant workers.

PBF indicator 1.3: Treatment success number of new smear positive TB patients.

(reporting Sputum conversion rate instead) (non-cumulative)

According to the cohort reporting timeline, the treatment success results of all Year 1 patients will

start reporting in the beginning of Year 2, therefore, there were no results of the treatment success to

be reported currently. Therefore, for the completion of the information to assess the quality of

treatment adherence of the project, we shall include sputum conversion rate of the TB patients in year

1 instead.

The Q1-Q3 average sputum conversion rate (SCR) is at 91% from 75 new smear positive patients

enrolled for treatment. The large variation of the sputum conversion rate in each quarter (84-100%) is

largely due to the small number of patients enrolled in each quarter. Many patients were detected

rather late and resulted with severe TB infections and some had died during the intensive phase. The

high sputum conversion rate can be the results of various factors as seen illustrated.

PBF indicator 1.4: Number of sputum-negative symptomatic patients tested for

culture (cumulative annually)

This indicator is a new indicator that was not included in the original proposal. This indicator had

been suggested by the TB expert during the M&E workshop for the PR assessment. In Thailand, the

NTP policy currently concentrates on the sputum-positive TB patients and not the smear-negative

patients, there are not many facilities around the country that can provide a timely culture testing

procedure. In Year 1, there are only two provinces that provide culture testing on a regular basis for

smear-negative patients, Phuket and Tak. Thailand MoPH-US Communicable Disease Collaboration

(TUC) has trained the government hospital laboratory staff to carry out culture testing for any patients

in the province, including migrants. All of the cases reported in Year 1 are the TB smear-native

patients from those two provinces only as the hospital protocols had also included the smear-negative

cases into their diagnosis procedures. However, in most hospitals outside the TUC collaboration,

this procedure has not been initiated and the TB RAM project staff has not been able to ensure the

culture testing services for the migrant patients in their care. Most of the smear-negative diagnosis has

been carried out mainly by sputum examination, chest x-ray and clinical examination of the patients.

This indicator is the only indicator that the project has not managed to achieve despite the small

targets set for year one. This is because the TB RAM project objective did not include health systems

strengthening for culture and DST for the smear negative cases.

Even in Year 2, this problem has not yet been solved and the project might have to review the

possibility of removing this indicator for Phase 2 implementation although the treatment of smear-

negative patients will continue and utilize the existing system provided by the government hospitals.

Number of sputum-negative symptomatic patients tested for culture

0

5

10

15

20

1 2 3 4

Quarters

No. of cases

Plan

Actual

PBF Indicator 1.5: Number of Secondary Service Delivery Points offering sputum

collection, DOTS treatment and TB/HIV counseling (cumulative annually)

In the Year I, a total of 14 Secondary Service Delivery Points (SSDPs) were established in six project

sites. The SSDPs are offering the sputum collection, DOTS treatment and TB/HIV counseling. The

higher number of achievement (Actual 14 from 10 planned) is due to the needs of more service

delivery points that can provide more access to the communities. SSDPs would refer to the offices or

clinics that can provide TB case management to the migrants with trained staff. ARC had set up more

SSDPs in their areas of implementation but the utilization of the SSDPs will have to be reviewed for

further plans.

Number of secondary service delivery points for Year I

0

5

10

15

1 2 3 4

Quarters

No. of secondary

service delivery points

Plan

Actual

PBF Indicator 1.6: Number of migrant health volunteers trained/retrained as DOTS

partners, TB/HIV counselling and referral, and community-based interventions


This indicator refers to the training sessions for the new recruits and for the existing volunteers for

refresher training. In Year 1, there were 1,310 volunteers trained and retrained by the project in 6

provinces. In the project, there are many activities for Migrant Health Volunteers (MHVs) training as

the MHVs are the key outreach migrant personnel to be able to do the followings:

• provide TB and HIV information to the communities

• assisting in recognizing TB signs and symptoms to call for referral of suspects

• provide initial counseling to suspects and patients

• carry out community-based interventions and advocacy for TB awareness among the migrant

communities

• most importantly, assisting in the DOTS treatment as a treatment partner

The MHVs are trained with the basic TB information as well as to act as DOT partners if there are

patients nearby their households. Other volunteer trainings include the intensive trainings for

relatives or neighbours who can act as DOT partners if there are no trained volunteers living nearby

the patients. There are many roles and activities for the volunteers in the communities. In the

indicator 3.1, the number of TB suspects of 1,170 is the direct results of the health education and

symptoms recognition by the trained community health volunteers.

One of the biggest challenges faced by the project is the mobility of the target groups. As the target

beneficiaries are “migrants”, it is difficult to retain volunteers in the community. Moreover, the

migrants are economic migrants and their income is the main priority for their survival. Many

volunteers did not continue their roles as they do not receive monetary incentives for their community

activities. The percentage of actual MHVs turnover rate has not been calculated but it has been

estimated that up to 30-50% of the volunteers had been replaced and retrained from these reasons.

0

500

1000

1500

1 2 3 4No. of MHV trained/retrained

Quarters

Migrant health volunteers trained/retrained for Year I (cumulative

annually)

Plan

PBF Indicator 2.1: Number of enrolled TB patients among migrants receiving VCT

with known HIV status (cumulative annually).

The Thai NTP guideline has initiated HIV testing in 2007 for all TB patients and included as part of

the cohort report (TB/HIV). The existing system for the government is for the HIV clinic counselor

to provide HIV counseling to the TB patients. For the migrant TB patients from SR-WVFT area, the

Migrant Health Workers FSNs were trained from the GFATM Round 2 HIV project to become HIV

counselors. Most of the cases that received counseling and testing from the project, were those

counseled and tested in the areas of WVFT implementation. The skilled counselors can provide an

effective percentage of the TB patients to receive HIV testing. A total number of 107 out of 168

patients or 64% received HIV testing and received the test results. Currently (as of 2008 information)

the NTP has tested about 30% of all TB patients for HIV and aiming to provide upto 65% of the TB

patients in 2009.

0

20

40

60

80

100

1 2 3 4

No. of cases

Quarter

TB patients receiving VCT and result of HIV test

Plan

Actual

PBF Indicator 3.1: Number of TB suspects (symptomatic) referred by migrant health

volunteers and/or community-based task force groups for sputum testing (non

cumulative)

The suspects referred by the volunteers in Year 1 had been increasing quarterly. The number of 1,170

suspects were the direct results of those identified by volunteers trained under the project. After some

discussions with the SRs, the PR found that the numbers had been under reporting to GFATM.

There were actually more suspects referred by the project but not necessarily by the volunteers.

Those under reporting suspects were found from

• Suspects who were identified by the FSNs and MLOs when the trainees recognized the signs and

symptoms described by the trainers.

• Household contacts of those living in the same household as the identified TB patients

• Walk-in suspects after reading the IEC materials produced by the project.

From this experience of under reporting from the project, there was a suggestion by the PR to

consider those under the above-mentioned categories from Q5 onwards.

However, one of the issues to consider when reviewing the planned and actual results of the suspects

referral will have to consider the unavailability of TB disease data among migrants. The targets of the

suspects calculated were from the “assumed” number of cases to be detected in the area. For

example, if there were 188 all TB cases/100,000 population per year for the Thai population, it can be

calculated that if 70% detection is to be achieved, there will be about 130 all TB cases to be detected

each year. From this number to calculate backward, it means that at least 1,300 suspects (or 10 times

number of cases) were to be referred. However, as there is no reliable data for TB among migrants,

the estimate that was used originally could be highly inaccurate. And as a result, the under

achievement maybe expected for this indicator In the future.

0

200

400

600

800

1000

1200

1400

1 2 3 4

No. of TB suspect

Quarters

TB symptomatic suspect referred by MHV

Plan

PBF Indicator 4.1: Number of secondary service delivery points that receives

supervisory visits, quarterly, in the past 3 months.

PBF Indicator 4.2: Number of DOTS facilities (secondary service delivery points)

which have a functioning DOTS registration

Both of the indicators mentioned above reflect the NGOs health system that had been set up to

support the migrants patients. In some areas, WVFT has established clinics prior to the GFATM

Round 6 implementation to increase health-seeking behavior of the migrants and they had become the

SSDPs to assist the migrants in TB screening and regular TB case management. Both WVFT and

ARC offices and/or clinics can provide DOTS as well as have functioning DOTS registration of the

migrants. This may not be necessary for a normal Thai population receiving TB treatment for the

NGOs to set up their own DOTS registration system. However for migrants, the government

hospitals may or may not be providing the full TB services for them. In that case, the system would

be set up to have TB patients records and reports generated by the NGOs to keep track of the TB

patients. The system established still follows the Thai NTP guidelines with additional information for

the community-based approach utilized by the project. All of the offices and clinics must receive

regular supervisory visits by both the SR core teams and the PR to ensure that their system is in place

and functioning effectively.

02

46

810

1214

16

1 2 3 4

No. of secondary service delivery points

Quarter

Functioning secondary service delivery points for Year I

Plan

Actual

Indicator

Number Indicator Targets Periodical targets for year 1

Year 1

P1 P2 P3 P4

Plan Plan Actual Plan Ac-

tual

Plan Actual Plan Ac-

tual

1.1 Case detection: Number of new smear-positive

patients detected 59 0 1 21 32 40 74 59 113

1.2 Treatment Enrolment: Number of new smear posi-

tive TB cases among the migrant population that

started DOTS-framework TB treatment program

with the assistance of a treatment partner.

38 0 1 10 32 24 71 38 106

1.3 Treatment success rate: Number and percentage

of new smear positive TB cases among the mi-

grant populations that are registered who are suc-

cessfully treated.

NA NA NA NA NA NA NA NA NA

1.4 Number of sputum-negative symptomatic patients

tested for culture (50% of smear negative patients

in each period ) (new indicator from proposal)

19 0 0 5 0 12 1 19 10

1.5 Number and percentage of secondary service de-

livery points (WV/ARC offices/clinic sites) offer-

ing sputum collection, DOTS treatment and TB/

HIV counseling.

10

2 1 7 7 8 8 10 14

1.6 Number of migrant health volunteers trained/

retrained as DOTS partners, TB/HIV counseling

and referral, and community-based interventions.

1045

170 121 480 613 855 443 1,045 1,310

2.1 Number of enrolled TB patients among migrants

receiving VCT and result of HIV test. 25 0 2 6 18 14 75 25 90

3.1 Number of TB suspects (symptomatic) referred by

migrant health volunteers and/or community-

based task force groups for sputum testing.

1,170 50 24 400 268 770 539 1,170 1,172

4.1 Number of secondary service delivery points that

receives supervisory visits, quarterly, in the past 3

months.

36 9 5 9 9 9 5 9 11

4.2 Number and percentage of DOTS facilities

(secondary service delivery points) which have a

functioning DOTS registration.

10 1 6 2 6 5 8 10 14

Lessons Learned

The implementation of the GF TB RAM Project has proven to be very challenging endeavor in many

ways, made more complicated by the political and legal status of the target migrant population.

Community Participation takes time. It was hard to achieve increased community mobilization and

participation in mobile migrant communities, under ACSM approach. Through the implementation

of phase 1, much more time is required to consolidate the community empowerment, self-reliance and

community networking in the project sites to achieve “from cough to cure” status in a sustained

manner. Expecting participation from these communities actually endangers the lives of community

members and is therefore an inappropriate expectation or requirement (Clark 2007). Issues to be

expected such as community members’ limited time to attend the trainings by health volunteers,

relatively small number of MHVs being assigned as DOT partners due to commitment factor and

little suspect referrals for diagnosis of TB by the community volunteers, had been encountered in the

year 1 implementation. Increased efforts have been made in the project sites to facilitate for target

groups’ lack of time. Activities were often planned to take place at the work place or where target

groups normally live. Health posts and MHV network groups have been established to encourage

community participation.

Difficulty of staffing and the need for capacity building. Shortage of the appropriate staff has

prevented project’s implementation in a timely manner. It was difficult to find staff to have other

ethnic language skills required for some project sites. Staff recruitments were delayed in some project

sites and consequently to the activities lagged behind the plan and budget spending. It also was

difficult to find and assign staff to expand new areas of project sites.

Increased capacity building is required for project staff in skills to facilitate community participation

and to enhance advocacy efforts in conducting meeting with community leader, business owner and local

authorities. Intensive advocacy effort is needed prior to implementation, especially in some

workplaces (factories or rubber plantation) where trust and credibility are yet to be gained. Regular

follow-up & testing for project’s health volunteers are required to ensure the effectiveness in their role

in case finding, suspects referral, information dissemination and generally mobilizing their

communities through participation.

Quality Data Assurance- Since data quality is crucial in monitoring and evaluating the progress of

the project. There is a need to improve quality of data being collected (valid and reliable) that can also

be verified at the project sites level. Capacity building of designated staff is required, skills in data entry

in registry, tracking and reporting system. The project may need to further adapt recording and reporting

forms to better fit the context of TB RAM.

Information, Education and Communication (IEC) Materials – TB brochures, stickers, posters

and other items have been created specifically for the target groups by TB RAM, however, there were

a number of factors preventing some of these materials to be fully effective for their purposes in

stigma reduction and improving health-seeking behaviours. All the materials produced were done in

Burmese and Thai, there is a proportion of the target group unable to read these materials. Other

proportion of the target group were able to read but were not able to grasp the not-so-simple

information in the brochures. More community participation is required in selecting the media to be

used for IEC materials as well as in designing message since communities should be acknowledged as

the primary holder of information and skills (Chambers 2005). Data gathered from KAP, FGD and

other surveys could be used to form stigma reduction messages.

The need for full government support – DST and culture testing facilities were not readily available

in all TB RAM project sites. Although this is an external factor, the project was unable to achieve its

targets in the area of culture testing and DST for patients under the project.

The Government’s policies towards migrants fluctuate greatly from government to government with

varying political agendas. The illegal status of both patients and MHVs in the project, restricted

movements and provided no protection against harassments by the authourities. Cross Border issues

had been inevitably raising concern of the border projects that it needs bilateral collaboration between

Myanmar and Thailand tackling that issues. Each project site had tackled these problems in various

ways. Certain sites utilize their existing, good relationships with local immigration officials to allow

more movements for the patients to complete the treatment. Some sites have issued Migrant

Volunteers ID card to allow MHVs to identify themselves to the authourities.

Lack of reliable data source for migrants - There was no available secondary data source for

migrants such as demographic, epidemiological, socio-economic, behavior surveillance and migration

pattern that was considered reliable. Some research studies of migrants were focusing mostly on HIV/

AIDS and Reproductive Health issues, not on TB issues.

Success stories

Although the TB RAM project sustainability is in question, especially with the mobility nature of the

target population in Thailand, it faces challenging questions such as Is Behaviour Change possible?,

Can the project see commitment from the government sector? Can the project see great desire for

improvement within migrant communities? And are we genuinely committed to the migrant

communities?

The success stories found in the following pages are a glimpse of its impact to the communities in the

first year of TB RAM’s implementation.

Achieving active participation requires a conscious effort. Participation is not automatic, nor can it be

assumed without developing relationships over time with their key stakeholder groups. Relationships

must be built with beneficiaries, other NGOs or community-based organizations and associations,

local religious groups and on local support networks (Clarke 2002).

Since the start of TB RAM’s 1st year implementation, each Sub-Recipient (WVFT & ARC) has

adopted an ACSM approach, as previously mentioned, in order to build a supportive environment for

effective TB control and prevention among mobile migrant population. Good collaborations have

been established with GOs and other relevant stakeholders as stated in the following report from SR-

WVFT & SR-ARC:

Collaborative Efforts (WVFT)

As Public-Private Mix DOTS (PPM DOTS) had been executed successfully since 2004 in TB

prevention and control program, the TB RAM budgets had been allocated to implement the

collaborative activities with public sectors, for achieving supportive environment for community TB

care, building capacity of service staff of hospital and public health office, developing protocols for

Facility-based Service Providers and supporting environment for development of coordination and

partnership.

Through PPM DOTS, WVFT has an advantage of accessing DST and culture tests services with

assistance of TUC surveillance programme in Maesot and Phuket to assess the seriousness of MDR

TB among Thai and migrant patients. Moreover, the project had been partnering with Maesot

hospital by installing a WVFT Burmese speaking medical officer in the Maesot hospital TB clinic to

assist in diagnosing migrant TB patients within the hospital. The hospital laboratory facility

performed and delivered a quality lab results with the assistance of microscopist training, supply of lab

equipment and chemical reagents procured by SR-WVFT.

In addition, WVFT had been having collaborative actions with Governor office, Immigration office,

Police department, Labour department in implementing Special Border Project over 10 years in

migrant issues.

Community events like World TB Day activities, health talks in the community and workplaces

(factories) were carried out to raise the awareness of the disease in cooperation with personnel of the

Thai health centers. Cooperation with Maesot General Hospital, community leaders and higher

authorities also went well resulting smooth implementation of the Special Border Project over 10

years on migrant issues in Maesot area.

Collaboration: Tongphaphum, Kanchanaburi Province (ARC)

Pilock Sub-district is such a remote place, which covered mountainous areas and isles along river. In

that rural place, population covers both legal and illegal migrants with Karen, Burmese or Mon origin

and was restricted to travel outside. There are various challenges for the SR to implement their work

with various barriers such as communication (language), distance, co-operation from Government and

from communities. The government at provincial and district levels were contacted to request for

cooperation and making clear with our objectives in Tongphaphum district. DPHO and Health

Centre staff allowed the SR to set up community health posts in the area and started to conduct joint

bi-monthly activities with the government. The SR went there from isle to isle conducting outreach

activities and found out that the language barrier had been one of the main issue in limiting the

communities to access health facilities with addition to having no Thai identification cards. Many of

them were suffering from TB disease and waiting for help.

ARC, District Public Health office and Health Centre staff had conducted regular outreach/mobile

clinic in remote area like Pilock by using MHVs to overcome the language barrier. In this way, all the

migrants in the area can have access to health services. The last trip of the year made a big impact to

the migrant community as well. Health post was set up, mobile clinic conducted, providing

community health education, MHV/community meeting as well as well as follow up supervision of 2

TB cases and DOT providers. By continually doing so, community felt that they were not neglected

of their basic needs – access to basic health services.

TB patient in Phuket (story provided by SR-WVFT)

41 years old construction worker in Ma HninZi site lived alone and had no relatives. Last year, he had

suffered from prolonged coughing and taken local remedies by himself but symptoms persisted and

the conditions became worse and worse. One day, he had coughed out blood and was taken to be

admitted at the local hospital in Phuket. The hospital did some investigations and diagnosed him with

TB and informed him that he needed to take anti-TB drugs for at least 6 to 8 months regularly. It was

very difficult for him to take anti-TB drugs regularly for a long time because he was an unregistered

migrant that could not access free medical care and therefore could not afford to pay for the

medication. He stayed at Hospital for nearly two weeks and took Anti-TB drugs regularly during that

period. When he recovered, he was discharged from the hospital. But unfortunately, he was too weak

to work and therefore he had no money to afford the anti-TB drugs and as a consequent, he could not

continue his anti-TB treatment.

Luckily for him, the construction site manager still allowed him to stay on their site even though he

could not work. After one month, he had suffered similar symptoms again but the same hospital did

not accept to him and transferred him to the provincial hospital for further treatment because his

condition was so severe, he was coughing up blood continually. Everybody thought that he was

definitely a dying man. There was nobody to support to him financially so he was discharged from

hospital.

Fortunately, WVFT GF 6 (TB RAM) project is implementing in Phuket. One of MHV, Ma Myint

Aye, has informed the case to WV staff. The staff met him and brought him to the provincial hospital

once again. WVFT has provided financial support for all cost of TB diagnosis and treatment as well as

food packages and nutrition, as he could not afford to buy medicines and nutritious foods. His

treatment started on 29 Apr 2008.

WVFT also provided trained DOTS provider who was residing in front of his room to ensure that the

patient take Anti-TB drugs in correct doses, at the right time and the right interval, ensuring the whole

duration of treatment and monitor any side effects of drugs. Under the supervision of DOTS

provider he has taken regular visit to hospital with the assistance of WVFT.

WVFT staff also have visited to him weekly and provided psychosocial support to take drugs

regularly. After two months, his sputum positive had converted to negative and he became physically

fit. After that, he has resumed his work as before. By the progress of the TB patient with a support

of WV, the people in the construction site were all surprised as he was revived from dying. Now most

of the migrants came to know that TB is curable, as they didn’t have knowledge on TB previously.

Now the migrants received TB information from WVFT and the volunteers trained.

The TB patient has continued with the treatment and he has made up his mind to become a MHV

with WVFT after completion of treatment. After such a visible outcome of the TB patient under

DOTS treatment, the people at the construction site decided to construct their own community health

post with their own funding. They had a regular meeting, assisted in facilitating referral of suspects,

detected another TB case and provided DOTS to the new patient. Attitudes of people toward TB

patients and the project are becoming positive. They plan to organize a community network group

and to create some Income-Generating Activities to support and to maintain the community actions.

Health post in Ranong (story provided by SR-WVFT)

The Thai U Dawn health post is situated in at the Concrete Mix Belching plant of Bangrin, Ranong

province. There were 200 Burmese migrants working at the site.

There were also some factories like saw mills and agriculture farms

around that site. Previously, people were not interested in

community activities as they struggled with their day-to-day work.

The owner provides barrack rooms for the those who come to

work which became a migrant commune inside the compound.

When one TB suspect was sent by an MHV from the compound,

he was diagnosed with TB and received TB treatment with

nutrition support from GF 6 project of WVFT. After that, the

people inside and nearby compound knew about WV and were interested in community health

activities.

Many people especially women come to attend the TB and HIV training and were recruited as MHVs.

Now there were altogether 15 MHVs around that area, in which more than 10 are women . The

women had more time to spare for community activities than men who were busy with day-to-day

work at the concrete mixing plant.

In the area of community interventions/mobilization, in reaching the inaccessible migrant population,

various community networks have been formed through the establishment of Community Health

Posts in all 6 provinces under TB-RAM project coverage. In Year 1, there were up to 66 health posts

have been formed in 14 districts. These health posts serve as a venue for health-related information

dissemination, patient referral, DOT & other health-related counseling services, community

mobilization and simply the meeting place of community-related activities beyond health issues. A

good example of a well-functioning community network can be seen in the following account by SR-

WVFT:

Community Health Talk in Mae Sot

Remarkable successes are identified in community mobilization as increasing awareness of the

community members in the TB disease and suspects are referred for testing; and the community

members requested the project staff to establish health post in their community and chose their

homes and selecting MHVs to man the health posts by themselves. MHVs stationed at Community

Health Posts have a very good attitude and are eager to contribute their time and efforts in reducing

TB burden in their communities in addition to allow using their homes as health posts without any

rental cost. They actively participated in the trainings and other activities of the program and tried

their best for their community, which in turn benefited the migrant communities as well as the

program. May be this is the reason that all the 12 health posts established are functioning although we

expect only one health post to be functioning out of 12.

Health post MHVs maintain the records systematically and accept any feedbacks for better services.

Total of 278 TB suspects were referred for testing, and 21 TB cases were referred from the migrant

health volunteers and health posts. MHVs at health posts also provided DOTS supervision and served

as DOTS providers when needed. They also help the patients as much as they can. Health post

volunteers also facilitated in other activities such as community awareness raising activities, follow ups

of MHVs in their community, organizing community-based groups to carry out meetings and

interventions at the community level.

Four CBOs were organized in four communities in Maesot and tried to serve and fulfill the needs of

community in the future and wanted to be models as good social network groups. They have set up

their goals; objectives and action plans and started community actions. All groups tried to make sure

that their activities would not distinguish their members from the other community members: they

tried their best to be representatives of their communities. They all have established a community

library in each community as income generating activities, running revolving funds for their

community with an assistance of the project. One CBO helped in the community event of monastery

activity. All the members of the groups are anxious and eager to help and fill the community needs as

soon as and as much as possible.

The set up of the community task groups in this project may not be only TB-related groups. After at

least 15 years of implementation of migrant projects by WVFT, it has been realized that an integrated

approach for the communities is the best approach. No communities will sustain their activities if it is

a disease-specific activity. They live as a community and therefore, there are various needs of the

communities on top of just TB disease control project. They demand other disease or health

information to ensure that their community members are well-looked after. The Community Health

Posts and TB networks are established to serve various needs of the community but concentrating

first and foremost on TB control. Other issues of community interest such as HIV, family planning

information, health care, or even anti-human trafficking should be included at the health posts set up

for the community. If the community feels that the health posts fulfill their information needs or act

as the central point for their communities, the usage of the health posts should hopefully outlast the

project and serve as one of the sustainable strategies for TB control in the future.

Conclusion

Although this report only summarises the first year implementation of the project, many of the

success stories or lessons learned can already be established from the SRs and PR. One issue that has

presented itself concurrently is that, the migrants have been the vulnerable populations in Thailand. It

is one of the factors why GFATM recognizes the needs to provide funding for this population. After

one year of implementation, the project feels that the vulnerability of the migrants either registered or

un-registered migrants will continue at various levels. At the national level, Bureau of TB has

recognized the importance of TB control among migrants at the policy level and therefore, migrants

and vulnerable populations had been part of the NTP guidelines. At the provincial or district levels,

there are needs of basic TB control among migrant populations that had partially been fulfilled by the

government facilities prior to the project implementation. However, the needs had been minimally

fulfilled. We still do not know the full extent of TB burden among migrants in Thailand but we

suspect that the burden is higher than the Thais due to their commitment to find work and income,

their living conditions and poor health-seeking behaviour. High HIV prevalence is also found to be

among the target groups the project covers. All these factors contribute to the infectiousness of TB

disease among the migrants that the project had tried to unearth from the first year. There were as

many as 106 smear positive cases among migrants in 14 districts of 6 provinces on top of those 259

smear positive cases in the whole of 6 provinces reported by Bureau of Epidemiology. TB RAM

project speculates that when there are more well-trained volunteers with enough coverage, they will be

able to identify more cases to be cured through the trained DOTS partners.

The project will continue to face various challenges from various sectors of government, both health-

related or national security-related officials at different levels. TB RAM project does not encourage

migration from the neighbouring countries through the project intervention. The project attempts to

alleviate the issue to establish a functioning model for the government to consider for future use.

This will require a monumental effort to collaborate with the government to accept the information,

strategy and successes established by the project.

The project hopes to see more collaboration, willingness and most importantly, commitment from the

government TB stakeholders in tackling the issue together in the future.

TB Reduction Among migrants in Thailand RAM Y1 Annual report.pdf · On top of the usual TB control...

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