The role of the community in TB control Dr Felix Salaniponi National TB Programme Malawi IUATLD Conference Paris, France 29 October - 2 November 2003

Outline of presentation Rationale for community contribution to TB care Model of integrated community TB care WHO-coordinated project “Community TB care in Africa” Project implementation steps and details of sites Results - treatment outcomes, cost and cost-effectiveness Conclusions Policy recommendations

Rationale for community contribution to TB care National TB Programmes (NTPs) need to ensure widespread access to effective TB care. Widespread access requires collaboration between NTPs and the range of health service providers: government and mission health facilities NGOs clinics in work places employer health services private practitioners including traditional healers community including household members.

Main focus of WHO efforts Geographical focus on settings where NTPs are increasingly unable to cope with case load by relying only on government health providers e.g. in Malawi TB bed occupancy rose above 200% Activity focus on improving DOT and treatment success

Model of integrated Community TB care TB SUSPECT TB PATIENT TB Officer TB Case TB Care TB Care NGOs/Private Provider community members hospital / health centre 5

WHO-coordinated project “Community TB Care in Africa” Collaborating agencies: WHO, UNAIDS, CDC, USAID, IUATLD, KNCV Aim: To evaluate community contribution to TB care in 8 district-based projects in 6 high HIV prevalence countries (Botswana, Kenya, Malawi, South Africa, Uganda, Zambia) Full details: IJTBLD supplement “Community TB Care in Africa” September 2003 Vol 7 No. 9, Supplement 1

Important features of district-based operational research projects to evaluate community contribution to TB care (1)

Important features of district-based operational research projects to evaluate community contribution to TB care (2)

Project implementation steps Establish links between services DHMT General health services District TB Officer Community organisations Training District level health workers Health centre workers Community project supervisors and volunteers Develop training tools educational materials

Treatment success rates (new sm pos PTB)

Reduction in cost ranges from 24% (Uganda, S Reduction in cost ranges from 24% (Uganda, S. Africa) to 71% (Malawi, sm+) Cost per patient to community volunteers from US$4 (Uganda) to US$14 (S Africa)

Pilot approach has less cost in all countries Improvement in cost-effectiveness ranges from 28% to 70%

Other benefits: Congested urban TB ward in Malawi in 1990s.

Other benefits: A decongested urban TB ward in 2001

Other challenges in case of Malawi Increased patients lost to follow up(in pilot phase LL = 12% of patients had unknown outcome) Questionable quality of DOT when patients lose or part with community treatment supervisors Delayed follow-up sputum submission Increases workload on peripheral / rural NTP staff Little involvement of HIV/AIDS care groups despite training (? Stigma) Poorer pqtients still hqve problems achieving a diagnosis

Conclusions 1) Communities can contribute to TB care in ways which are effective, cost-effective and affordable where health services, the NTP and community organisations collaborate successfully mechanisms are set up for referral, logistics, training and patient education 2) Need to promote mainstreaming of community TB care as part of routine NTP and HIV activities – including reducing barriers to diagnosis for the poor

Policy recommendations (1) 1. NTPs should harness community contribution to TB care where there is a need to improve access to care and quality. 2. An effective NTP is necessary to handle the extra management responsibilities. 3. Ensuring effectiveness of community members as TB treatment supporters: identifying the right group training links with NTP and health service providers maintaining motivation e.g. by Frequent supervision 4. Peripheral health units and community TB treatment supporters need to contribute to recording and reporting.

Policy recommendations (2) 5. NTPs should ensure an effective, secure and safe system of drug supply to TB patients and community treatment supporters. 6. NTPs should monitor community contribution to TB care using standard NTP performance indicators, % of patients choosing different DOT options, and quality of care indicators(Loss of guardians, safekeeping of drugs/records, referral systems, ward round at hospital)

Policy recommendations (2) (cont’d) 7. Ministries of Health need to ensure adequate financing, on account of the new costs involved, while recognising the cost-effectiveness of this approach. Government Commitment: ٠ Stationery (DOT ٠ Monitoring Forms ٠ Training of Peripheral Staff ٠ Expanded DTO supervision of Health Centres 8. Sustainability requires commitment of MoH, NTPs, donors and NGOs. 9. Expansion involves developing costed plans and clear criteria for choosing districts targeted for expansion. E.g. in Malawi and expansion plan was, done in 2000 and implementation of countrywide expansion finished in July, 2001

WHO documents on community TB care Community contribution to TB care: practice and policy (WHO/CDS/TB/2003.312) WHO communicable disease documentalist: cdsdoc@who.int WHO Stop TB website www.who.int/gtb Thank You