Current status of integrated community based TB service delivery and the Global Fund work plan to find missing TB cases Tanzania Dr Peter Asilia – AMREF
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Current status of integrated community based TB service delivery and the Global Fund work plan to find missing TB cases
Tanzania
Dr Peter Asilia – AMREF
Background • Tanzania is one of 30 highest Tuberculosis burden countries in
the world.
• In 2016:
– 65,908 (40%) TB cases were notified (out of the estimated annual incidence of 160,000 cases) and initiated Anti-TB; this implies 90,000 TB cases missed.
– 158 MDR TB cases were initiated treatment out of 196 detected cases (estimated annual case incidence 830 MDR TB). 672 MDR TB cases missed
• Community based TB activities are designed to sensitize/mobilize for community engagement in identifying TB cases; TB diagnosis using Lay counselors and sputum fixers; and early referral to HFs for TB treatment and support
• National coverage of community based TB activities is 100% (185 Councils).
– Activity varies base on the type of available support.
• National coverage of recording and reporting of community based TB activities is 100% (all 208 BMUs). Through electronic system.
Key community stakeholders with coverage
Cadre implementing
community based TB
activities in the
country
NGO/other
CBOs/Minis
try of
health/
other
Responsible
agency
Geographic
coverage
Amount of
funding
allocated in
2017-2018
Community volunteers CBOs, KNCV -
Challenge TB
6 regions
(47 councils)
$630,061
Community
Volunteers (Ex TB
patients/ Sputum
fixers), Traditional
healers)
AMREF
Gov
Global Fund 8 regions
(55 councils)
3 Regions (17
councils)
$2,191,080
Community
Volunteers (Ex TB
patients/ Sputum
fixers
CSOs USAID
Boresha afya
12 No clear data
Community Health
volunteers
CBO LHL 7 councils No clear data
MAPPING OF PARTNERS ON COMMUNITY TB INTERVENTIONs IN TANZANIA 2018/2020
Global fund
Deloitte, Tanzania
KNCV TB Foundation, Tanzania
EGPAF, Tanzania
The Norwegian Heart and Lung Patient
Organization
MAPPING OF COMMUNITY HEALTH VOLUNTEERS 2018
Key
EX-TB Clubs
Sputum fixers
Implementation mechanism
Entity Implementation
arrangement
Resources Implementin
g cadres
Salary/incen
tives/Other
NTLP/
AMREF
Selection of
CHVs Training in
collaboration
with NTLP
Support
(Incentive and
monitoring)
$2,191,080 (7.5% of total budget)
CHVs (Ex
TB patients,
sputum
fixers) and
Traditional
Healers
Sputum
fixers ($25
monthly
allowance,
$10 transport
allowance)
Ex TB
patients
Implementation mechanism
NTP/AMREF
KNCV
DELLOITE
EGPAF
DISTRICT
MEDICAL
OFFICER
HEALTH
FACILITIES
COMMUNITY
HEALTH
VOLUNTEERS
• Coordination
• Define
Strategies/interventions
• Support Implementation
through funding, M&E tools
and governance
• Supervision and Training
• Report analysis and quality
Improvement
• Ensure
Accountabilit
y during
implementati
on
• Oversee all
the activities
related to TB
in the district
- Identify CHVs
(ex-TB
patients,
sputum fixers
and Traditional
Healers)
- Prepare
budget for
implementation
(transport and
monthly
allowances;
incentives)
- Oversee day to
day functions
of CHVs
- Must have tools
necessary to
implement
activities
- Must report every
week
- Must ensure the
Village Health
Committee is
aware of all the
TB community
activities
MoH
TWG CSOs
Support for implementation
Item Support
Support from
national TB
programme
• Technical assistance
• Guidelines and tools
• Training facilitators
• Equipment and supplies especially for sputum fixers
Training/capacity
building strategy
for CHWs/CVs
• Training/ Refreshers on the start of the intervention
• Mentorship – conducted during quarterly meeting
• Provision pf Community TB care handbook – in
Swahili
• Provision of IEC materials
Supervision
mechanism
• Annual Joint supervisions – NTLP and Partners
• Semi-annual regional supervision
Monitoring and
evaluation of
CHW/CV
performance
• Quarterly data verification meetings
Available implementation tools (please use actual pictures where possible)
Document Existence
1 National guidelines for community based TB activities
YES
2 Referral mechanisms and tools (for presumptive TB)
YES (Form TB 15)
3 Job aids for referral, diagnosis and treatment of TB
YES (SOP for sputum fixers,
Handbook for CHWs)
4 Recording and reporting tools
YES (TB12, TB13 A&B,
TB14, TB 15)
5 Tools to ensure treatment completion and patient support
TB 02, TB 13B
6 Any others?
National ENGAGE TB Operational Guideline
YES
Community TB Guidelines documents
TB 12
Jina la Mwanakikundi/Mtoa huduma za afya ngazi ya jamii………………………………………………….. Jina la Kikundi/Asasi…
Jina la kitongoji /Mtaa…………………………………………..kata…………………………..wilaya……………………………..
KH D H KU KJ Hana
dalili
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Kielelezo A: Kielelezo B:
1.Shule 5.Duka la Dawa 1.Hana TB
2.Nyumba za Ibada 6.Magereza 2.TB kwenye makohozi
3.Machimbo 7. Waganga wa tiba asilia 3.TB sehemu nyingine
4.Mikutano ya hadhara 8. Mengineyo (jata) 4.Rufaa haijafanikiwa
Maoni
Matokeo ya
rufaa (angalia
kielelezo B
* KH= Kikihozi. D= Makohozi yaliyochanganyika na Damu, H= Homa, KU= Kupungua uzito, KJ = Kutokwa jasho jingi kuliko kawaida hasa nyakati za usiku
*Dalili alizonazo
Matokeo ya mahojianoJina (majina matatu) Mahali alipotokea mteja/alipohojiwa (Weka
Mgang
a wa
jadi
Familia
isiyo na
mgonjw
a wa
Jinsi
(me/ke)
Jina la kituo
cha tiba
alichopewa
rufaa
Namba ya simu
ya mteja
Wizara ya Afya, Maendeleo ya Jamii, Jinsia, Wazee na Watoto
Tarehe
Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma
Mwezi wa kutolea taarifa(mm/yy)……/……/…………………….
Fomu ya watu (wateja) waliofanyiwa uchunguzi wa awali wa TB na DR-TB katika Jamii
Umri
(miaka)
Na Namba ya
simu ya mtu
wakaribu
Familia yenye
mgonjwa wa
TB/DR-TB
(Andika namba
Mkusanyiko
wa
watu/sehem
u nyingine
Community TB M&E tools
TB 15
WIZARA YA AFYA, MAENDELEO YA JAMI, JINSIA, WAZEE NA WATOTO
Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma (NTLP)
(Huduma shirikishi za TB, TB/UKIMWI na TB Sugu katika jamii)
Fomu ya rufaa.
1. Sehemu hii ijazwe na Mwanakikundi wa kikundi cha waliougua na kupona TB au TB sugu nk.
Jina la mgonjwa( Majina matatu)
……………………………………
Umri(Miaka)……………………….
Namba ya HUWANYU………………….
Namba ya CTC……………………..……
Tarehe ya rufaa (Siku,Mwezi, Mwaka)
………/………/………
Jinsi
o Me …………
o Ke………
Rufaa kutoka
Jina la Kikundi
…………………………………
Jina la mtoa
rufaa………………………………
Namba ya mtoa rufaa…………………………
Namba ya
simu……………………………….…
Sehemu nyingine (Shirika/taasisi)
Jina…………………………………….………..
.
Rufaa kwenda
Jina la kituo cha
tiba.....................................................
Wilaya:………………………………………………
…
Dalili za TB (Tiki panapohusika)
o Kikohozi zaidi ya wiki mbili
o Homa zaidi ya wiki mbili
o Kupungua uzito
o Kutokwa na jasho usiku zaidi ya wiki
mbili
o Maumivu ya Kifua
o Kukohoa makohozi yenye mchanganyiko
na damu.
Zingatia:
o Uchunguzi na matibabu ya TB na TB sugu
hutolewa bila malipo.
o Kwa WAVIU ni kikohozi cha muda wowote
×……………………………………………………×…………………………………………………………
…×
2. Sehemu hii ijazwe na mtoa huduma wa kituo cha tiba.
Jina la Kituo cha Tiba
……………………………
Jina la mteja
…………………………….
Huduma ya ugunduzi iliyotolewa.
o Upimaji wa makohozi
o Upimaji wa VVU
o X-ray
o Upimaji wa daktari (Physical examination)
Tarehe ya kupokelewa
mgonjwa.(Siku,Mwezi,Mwaka)
……/………/……
Matokeo ya vipimo
o Kuwepo kwa vimelea vya TB
o Hakuna vimelea
o Kifua kikuu nje ya mapafu
TB 13 A
Jina la kikundi/Asasi/ Mtoa huduma za afya ngazi ya jamii:______________________________
Hana
TB
TB kwenye
makohozi
TB sehemu
nyingine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Kielelezo A:
1 Familia yenye mgonjwa wa TB/DR-TB (Andika namba ya wilaya ya mgonjwa wa TB/DR-TB
2 Familia isiyo na mgonjwa wa TB/DR-TB
3 Mkusanyiko wa watu/sehemu nyingine (weka namba, Taja kama ilivyoandikwa kwenye fomu ya TB 14)
4 Mganga wa jadi
REJESTA YA WANAOHISIWA KUWA NA TB/DR-TB KATIKA JAMII
Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma
Wizara ya Afya, Maendeleo ya Jamii, Jinsia, Wazee na Watoto
Amepima
VVU
(weka N
kama jibu
ni ndiyo,
H kama
jibu ni
hapana)
Tarehe Jina (majina matatu) Jinsi
(Me/Ke)
Umri
(Miaka)
Makazi
(Mtaa/kitongoji;
namba ya simu
kwa chini)
Sababu ya
rufaa
(Kupima
makohozi;
Kurudi
kwenye
matibabu;
Kupima
VVU;
Mengineyo)
Na Jina la kituo
cha tiba
alichopewa
rufaa
Maoni/
Maelezo
mengine
Matokeo ya rufaa (weka √
panapohusika)
Matokeo ya
matibabu
kulingana na
rejesta ya
kituo cha tiba
(TB03/ DR-
TB04)
Ameanza tiba
ya TB (weka √
kama ameanza
na namba ya
TB/DR-TB kwa
chini)
Mahali
alipotokea
mteja/alipo
hojiwa
(Kielezo A)
TB 13 B
Jinsi
(Me/Ke) Ameanza
matibabu ya
TB/DR TB
Hajaanza
matibabu ya
TB/DR TB
Mtaa/
Kijiji
Balozi/
Mwenyekiti
wa
mtaa/kijiji
Namba ya simu ya
ndugu/mtu wa karibu
Amepatikana Hajapatikana Amefariki
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Amerudi
kwenye
matibabu (ndio
au hapana)
Kama
hapana, toa
sababu
Maoni/
Maelezo
mengine
Sifa ya mgonjwa
anayefuatiliwa (Weka alama
ya Vema panapohusika)
Wizara ya Afya, Maendeleo ya Jamii, Jinsia, Wazee na Watoto
Mpango wa Taifa wa Kudhibiti Kifua kikuu na Ukoma
REJESTA YA WAGONJWA WA TB/DR-TB WALIOKATISHA/WASIOANZA MATIBABU
Jina la kikundi/Asasi/ Mtoa huduma za afya ngazi ya jamii:______________________________
Tarehe ya
ufuatiliaji
Jina (majina matatu), chini andika ya
namba TB/ DR TB ya wilaya ya
mgonjwa kama alianza matibabu
Umri
(Miaka)
Matokeo ya ufuatiliaji
(weka alama ya Vema
panapohusika)
Mahali alipotokea mteja/alipohojiwa Na.
M&E: Data collection and data flow structure
TB 03 (Unit Register)
Self Referrals Community referral - from
CHWs (Form TB15)
ETL (Case Based)/
DHIS2
TB 01
Jina (Majina matatu): Namba ya Wilaya
Anuani ya Makazi: Jina la Kituo cha Tiba
Kiongozi wa mtaa/Jirani:
Namba ya simu (kama ipo): Mahali pa matibabu
Jinsi Umri (miaka) Aina ya Kifua Kikuu Aina ya Mgonjwa
Pulmonary New
Rufaa na: Previously treated
Relapse
Extra-pulmonary Site:___________ Failure
Lost to follow up
Others (specify) ____________
Taarifa za Msimamizi wa Matibabu HIV Status*: Neg
Jina la msimamizi wa matibabu:
Anuani ya Makazi:
Namba ya simu ya msimamizi wa matiababu: HIV Care Registration No:
Uhusiano na mgonjwa
Mwenzi CPT Start date No
Mwanafamiliya Pre ART care Start date No
Jirani/Rafiki Start date No
Mfanyakazi ngazi ya Jamii
Nyingine (Taja) ___________________________________
Wizara ya Afya na Usitawi wa JamiiMpango wa Taifa wa Kudhibiti Kifua Kikuu na Ukoma
KADI YA MATIBABU YA KIFUA KIKUU
Binafsi
Jamii
CTC
Nyingine (Taja)
* HIV status: Pos: Positive, Neg: Negative
NdiyoART drugs
Mme Mke
NyumbaniKituo cha Tiba
Ndiyo
Ndiyo
Pos Haijulikani
TB treatment card (TB01 which feed TB03)
M&E ............. • Data systems (status of DHIS2 adoption)
– Well functioning countrywide
– Reentry modified to case based system
• Data elements collected
– Notification by type of a patient, by sex, by age
– TB/HV data
– Referral status (from community/ self)
– Patients transfer
– Treatment outcome
M&E........... • Community TB indicators in DHIS2:
– Number of referred Presumptive TB cases from community
– Number of TB cases notified from community referrals (all forms)
– Number of bacteriological confirmed TB case notified from community referrals
– Number of TB patients under Home Based DOT
– Number of TB patients under HBDOT successfully treated
• Geographic coverage of monitoring and evaluation and related tools is uniform countrywide
• Services linked to other sectors in the community; linked to other health plans and interventions such as Chronic Lung diseases (NHL)
• Comprehensive monitoring and supervision visits have proven to be efficient
• However, there is a need to strengthen coordination of stakeholders engaged in the community
Integrated TB service delivery
Community
HFs
CSO
Other sectors
Community
leaders
Mechanisms for coordination of community based TB activities
• Availability of Formal coordination mechanism e.g. NTP-NGO coordination body o Established recently through EANNASO under Stop TB
partnership support “Tanzania community TB Forum”
• Key functions of the forum
o Oversee implementation of Community TB care intervention and advocate to for improvement
o TB Community voice
• How frequent are their meetings
o Annually (last meeting – 2017 for establishment) supported by EANNASO under stop TB partnerships ,
• Any funding support? o Global Fund
Challenges, Bottlenecks and Solution
Challenges/ Bottlenecks
Solution
Coordination
Inadequate Funds
Lack of transparence
(Some partners)
Fund mobilization for regular
Coordination meetings
Service delivery
Difficult referrals and
treatment support, and
follow up of homeless
community
Peer groups
Monitoring and evaluation
Linking community TB
data with the system
(TB03: TB unit register)
in some of HFs is still a
problem.
Regular supportive supervision
and mentorship
Involvement of DOT providers
during community TB quarterly
meetings in each BMU.
Success story: model for community based TB activities suitable for nationwide scale-up
Sputum fixers in Kondoa District (Rashid Gora) • This is a Community person trained in 2016 as a sputum
fixers under GF support.
• He is working with almost five dispensaries and their catchment area for sputum collection, smear, fixing and transport the slides to Kondoa district hospital for TB diagnosis
• In 2017, Gora ( just one sputum fixers) had contributed 59 TB case in the country equivalent to 0.09% and 12% in Kondoa district.
• Lesson leant: Investment in Sputum fixers can increase much in TB case detection rate in countries.
Success story model for community based TB activities suitable for nationwide scale-up
https://www.theglobalfund.org/en/specials/2017-10-09-tb-
heroes-of-the-hinterlands/
Results
– Treatment success = 90% National coverage
– Treatment success : Home Based DOT – 91.1%
– Defaulter 2% and Death 2%
0%
5%
10%
15%
20%
Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 2016 2017
7%
10%
6%
10%
15% 15% 15%
20%
8%
16%
6% 5% 4%
6%
9%
11% 10%
15%
10%
14%
TB
CA
SE
S A
TT
RIB
UT
ED
FR
OM
CO
MM
UN
ITY
RE
FF
ER
RA
LS
(%
)
PERIODS: 2016 - 2017
Tremendous increase of community contribution in TB case notification in Global Fund supported regions from 2016 - 2017)
GF supported regions National coverage
Country work plans for community based TB activities
Stated
objective/
Module
Key
stakeholders for
implementation
Geographic
coverage/stakehold
ers
Percentage of TB
BMUs covered by
current GF grant
TB care and
Prevention –
Community TB
delivery
NTLP 3 regions (Rukwa,
Kigoma, Katavi)
72 BMUs / 208
BMUs (35%)
NTLP/ AMREF 8 regions (Dodoma,
Shinyanga, Ruvuma,
Kagera, Mbeya,
Simiyu, Mara, Tanga)
Country specific opportunities
• Opportunities to increase community engagement to achieve targets listed on previous slide • Formalization of Community Health Worker cadre
• The country Plan is to have 2 CHWs per village (20,000 villages countrywide)
• Presence of willing CSOs to engage TB control activities in the country
• Recent modification of Electronic TB and Leprosy system to
be case based. – This will increase data verification concerning community referrals
Anticipated implementation challenges and suggested solutions
Anticipated challenges Suggested solutions
Delay of implementation – PR2
(First quarter – No
implementation)
PR2 to immediately start
implementation
Duplication of efforts among
stakeholders
Enhanced coordination at the
National level and proper
planning
Thank you
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