Current status of integrated community based TB service delivery … · competitive recruitment process that is endorsed by both TBICC and KCM. ... 2015 5.4% 2016 6.4% 2017 8.5% .

Current status of integrated community based TB service

delivery and the Global Fund work plan to find missing TB cases

Team Kenya

Background

Counties 47

Sub Counties 269

Prevalence 426/100,000 (Prevalence Survey

2015/16)

Incidence 348/100,000 translating to 169,000

cases annually

Case notification 2017 85,188 (9.1% children); still missing

approximately 50% of the cases

DR TB case notification 577 cases notified in 2017

Increasing trend since 2014

Contribution of CHVs to

TB case notification 2017

8.5%

CU coverage 59% fully functional

Programme gaps and role of community based TB activities

1. Inadequate documentation of community based TB activities

• Recording and reporting tools not harmonized (different partners with different tools)

• Available tools do not adequately capture contribution made from community based TB activities (referrals, case finding, IPT uptake, retention

• Inconsistent supply of recording and reporting tools

• Competing tasks/high workload for CHVs and HCWs

• Data flow from CHVs to National TB program is poor

• Low/lack of motivation

Programme gaps and role of community based TB activities

2. Uncoordinated efforts among various stakeholders – no community TB TWG

3. Inadequate resources to maintain CHV stipends – currently largely donor dependent

4. Lack of intensive community awareness efforts

5. Limited coverage of community health units hence implementation

through individual CHVs in some areas – quality of work affected

6. Insufficient integration of TB into other community outreaches and activities – missed opportunities

National coverage of community based TB activities expressed as percentage of TB basic management units (BMUs)

• All health facilities – Approximately 10,000

• TB Treatment sites – 4,300

• Coverage of community based TB activities – 1 CHV trained per TB treatment facility

• Coverage of recording and reporting of community based TB activities – since they all document to varying degree the referrals by CHVs

Key community stakeholders with coverage

• Amref Health Africa in Kenya is the Principal Recipient for non-state actors under the Global Fund TB grant

• From Oct 2015 – Dec 2017 Amref sub granted 29 CSOs to implement Community TB control activities in all the 47 counties in Kenya.

• Key activities include; Training of CHVs and CHEWs on community TB care, household health education and contact investigation, tracing of treatment interrupters, community outreaches, screening in Prisons, training HCWs on infection prevention and control (IPC).

• Amref through the Global Fund country coordinating mechanism is in the final stages of recruiting Sub Recipients for 2018 – 2021 GFTB grant

Implementation mechanism

• The Technical Review Panel (composed of NTLD-P, Amref and other stakeholders) recruits CSOs through a competitive recruitment process that is endorsed by both TBICC and KCM. (Current grant desk review was done)

• Each CSO has a catchment area (county, sub county), and performance is reviewed periodically

• Amref has a budget of USD 32,651,550 for the 2018 – 2021 grant - Community TB activities comprise 47% of the budget

Implementation Mechanism

Cadre Coverage and role Incentives

1 CHVs At least one trained in each

TB treatment site

$8.4 per household

visited ($11 in hard to

reach areas), $20

monthly under CSS

2 CHEWs/PHOs/PHTs One in every TB treatment

site Supervision of CHVs

$2.5 airtime monthly

3 Health Care Workers Facility level

Documentation; initiating

tracing

Proposed airtime for

tracing of patients

interrupting treatment

4 County and Sub County

Health Management Teams

Supervisory role at county

and sub county level

N/A

5 CSO (SR) staff

Implementing partner at

county/sub county level

N/A

6 NTP and Amref Health Africa National level

Policies, planning,

monitoring, TA

N/A

Support for implementation

Support from National TB programme

• Joint development and dissemination of policy and guidelines

• Capacity building

Training of CHVs and CHEWs on community TB under Global Fund NFM grant

Sensitization of CHVs on community TB, TB patients charter and TB/HIV under current grant

• Technical assistance

• Research and development

• Coordination of stakeholder engagement forums

• Participation in periodic quarterly review meetings for CSOs

Support for implementation

Support from the county

• Supervision mechanism

CHVs are supervised by CHEWs (CHEWs are in areas with active CUs)

SCTLCs verify forms filled by CHVs before submission to SR for payment; data review meetings; facilitation of trainings

• Monitoring and evaluation of CHV performance

CHV feedback meetings

Under integrated CSS pilot – monthly performance monitoring form filled by CHEWs for CHVs in their CUs

Implementation tools

Tool Availability and use

National guidelines for community based

TB activities

Available though not updated

Referral mechanisms and tools (for

presumptive TB)

Referral forms are available though not in

all facilities. Weak linkages from the

community to the facility

Job aids for referral, diagnosis and

treatment of TB

Available at health facilities targeting

HCWs

Recording and reporting tools Available though not optimally utilized

Tools to ensure treatment completion and

patient support

Available

TB screening tool at community level

Contact investigation form

Treatment Interruption Tracing Form

Implementation tools

Monthly Summary Form Community Referral Form

Contact register

Monitoring of community activities

•Fills Monthly reporting tool

CHV

fills Summary

tool & reports via

DHIS

CHEW

Compiles and submits

report through

TIBU

S/CTLC

NTLD receives

data from TIBU

NTLD

CHV Tools • Community referral • Community screening

tool • CHV reporting form • Contact tracing form • Treatment interruption

tracing form

CHEW Tools • CHW Summary tool • Chalk board

Ideal though not happening

Monitoring and Evaluation

• Data systems (status of DHIS2 adoption)

• Currently on test platform (TIBU/DHIS integration)

• Meeting planned soon to push data to live platform

• Data elements collected

• DOT by CHVs

• Referred by CHVs

• Are there Indicators used to track contributions of community health workers/volunteers to:

• New TB case notifications – Yes, though not accurate due to missing information

• Treatment success - Partly

• Tracing treatment interrupters, contact tracing - Partly

Integrated TB service delivery

Integration (how, what and who) of TB activities at community level

• CSS pilot done in three counties – Homabay, Kwale, Vihiga (results overleaf)

• Community recording and reporting tools revised to capture key TB, HIV and malaria indicators

Service delivery linkages with national TB programme

• Process starts at county entry where the CSOs are introduced to the CHMT

• Work plan of activities is laid out; program officers and CTLC help plan for this meeting

Baseline and Midterm findings

Baseline (n=312) Mid term rapid assessment

We have also witnessed improvement of other indicators for TB, HIV and Malaria. However, there is still much to strengthen including reporting by CHVs, data quality and improvement of implementation of all

activities

Percentage of CHVs offering Specific TB services in the three counties

Mechanism to support integration

Regular meetings between public health and community stakeholders • CSOs participate in National TB Programme quarterly review meetings

• National TB programme and CHDU participates in AMREF GF TB quarterly review meetings

• National TB program biannual review meetings

Does routine NTP supervision/review include community-based TB services

• Yes, during routine TA missions, the community aspect is discussed; previously no specific tools to capture this in the comprehensive tool

• SCTLCs verify community tools before CHVs are remunerated

Joint data validation exercises • Program officers are invited for CSOs quarterly review meetings

• CSOs get to attend the routine QRMs where data validation is done

• Biannual Onsite Data Verification involving PR, SRs, C/SCTLCs

Mechanisms for coordination of community based TB activities

Formal coordination mechanism e.g. NTP-NGO coordination body

• TB ICC – Quarterly

• Ratify PR proposals and performance reports

• KCM – Quarterly

• Endorse decisions from the TB ICC

Challenges, Bottlenecks and Solution

Coordination

• Challenges • Poor intra-sectoral and inter-sectoral collaboration - Inadequate

linkage to community units

• Limited resources

• Weak cross border linkages and mechanisms

• Solutions • Policy guidelines

• Resource Mobilization

• Incorporation of community activities into the county strategic plans

• Develop robust cross border policies

Challenges, Bottlenecks and Solution

Service delivery • Challenges

• Low morale among CHVs and CHEWs

• Solutions • Motivation (financial, capacity building)

Monitoring and evaluation • Challenges

• Erratic supply of RR tools • Incomplete records

• Solutions

• Consistent supply of RR tools • Regular OJTs • Performance based incentives

Results

Treatment Outcomes

TSR Death rate LTFU

All cases 84.2% 5.7% 4.7%

Referred by

CHVs 85.2% 6.8% 5.5%

DOT by CHVs 81.5% 6.0% 6.8%

Contribution by CHVs

Year Contribution by CHVs

2015 5.4%

2016 6.4%

2017 8.5%

Success story

Targeted Outreaches using digital X-ray machines – Drug Dens in Mombasa

No.

screened

Clinically

diagnosed

Changamwe 70 15

Kisauni 86 18

Bamburi 92 25

Mvita 188 41

Likoni 40 8

Total 476 107

Numbe

r

Tested

Number

MTB

Positive RR

Positivity

Rate

Bamburi 50 1 0 2%

Mlaleo 72 3 1 4%

Mvita 161 8 0 5%

Likoni 40 0 0 0%

Changamwe 49 5 0 10%

Kongowea 35 3 0 9%

Total 372 20 1 5.4%

Screening at the bus/matatu stages in Kakamega

No done

x-ray

Suggestive of TB Gene Expert

done

MTB Pos Remarks

Totals 387 16 317 7 18

patients

Improving documentation of community TB activities

• Facilities reporting 10 or more cases monthly, supported to hold

monthly meetings to review community TB data under NFM.

• Total of 106 facilities were supported

• Key meeting participants: Health care worker manning TB clinic, CHEW, CHV

• The proportion of TB cases referred by CHVs increased by 59% from 2015

to 2016 in the 106 facilities.

• Link CHVs were stationed at 80 high burden facilities in 16 counties

with case notification of <175/100,000

• Key roles: Assist referrals from the community to navigate through facility departments and ensure they are correctly documented if found to have TB

• Received a monthly stipend of Ksh 5,000

• The proportion of TB cases referred by CHVs increased by 14% between April

and December 2016 in the 16 counties

• Sub county data review meetings

Country work plans for community based TB activities

Country work plans for community based TB activities

• Stated objective – • Project contributes to the goal and objectives of current

National TB Strategic plan 2015 - 2018

• Key stakeholders for implementation • National TB Programme • Community Health and Development Unit • Amref Health Africa in Kenya and Sub Recipients • County and Sub County Health Management teams

• Geographic coverage/stakeholders • All 47 counties under the GF grant

• Percentage of TB BMUs covered by current GF grant • 100% since targets are set based on number of all facilities

notifying cases

Country specific opportunities

• Opportunities to increase community engagement

• Implementing the TB County Innovative Challenge Fund

• Targeted Outreaches using mobile digital X-ray machines

• Corporate TB screening

• Engaging county based TB champions to advocate for resources and create awareness on TB at community level

• Multi-sectoral approach

Anticipated implementation challenges and suggested solutions

No. Challenge Proposed solutions

1. Delayed implementation due to SR

engagement process

• Accelerated work plans by SRs

• PR to fill in gaps in vacant counties

2. Poor documentation in community TB

recording and reporting tools

• Introduce incentives/motivation e.g.

including correct documentation in the

pay for performance concept

3. Attribution of notified cases to specific

interventions at community or facility level

• Revise recording and reporting tools to

capture all community TB interventions

accurately

• Enhanced technical assistance

including WHO, KIT, Strategic Initiative

4. Proposed revision of tools could lead to

further delays

• Fast track the process of revision,

approval, procurement and roll-out of

proposed tools

Anticipated implementation challenges and suggested solutions