Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. Stopping TB through social mobilization and community partnerships Adhi Sanjaya Adhi Sanjaya Milton Amayun Sri Chander Presented in 34 th Annual International Conference on Global Health and CCIH 2007 Annual Conference 34 th Annual International Conference on Global Health and CCIH 2007 Annual Conference Lessons learned from FIGHT Project

REPUBLIC OF INDONESIA

MANGGARAI EAST SUMBA KUPANG DISTRICT BELU NGADA WEST SUMBA ALOR ENDE SIKKA TIMOR TENGAH SELATAN (TTS) LEMBATA EAST FLORES TIMOR TENGAH UTARA (TTU) ROTE NDAO KUPANG CITY SABU ISLAND MAP OF NTT PROVINCE 2004 Islands566; 43 inhabited Population4,165,568 (2004 census) Land / sea ratio1 : 4.2 Administrative15 districts + 1 municipality

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 4 NTP in NTT (2000) Low Case Detection Rate Low Cure Rate Less coverage of DOTS service Poorly trained health staff in NTP High ratio of population per health staff Weak collaboration between HCs (DOTS provider) and hospitals or private health provider Low level of community involvement in health programs.

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 5 FIGHT Project Food integrated to hinder tuberculosis. Funded by CIDA, March 2000 – Sept Covers 5 districts, total population 1.1 M. As a partner of government’s NTP. Goal: “To contribute to the decrease of TB mortality and morbidity among people of NTT province”. Work focus: district level.

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 6 FIGHT Outcome Objectives Improved and sustained quality DOTS TB program management Increased participation and commitment of district government and TB DOTS implementers in TB control program Enhanced community participation in improving a sustainable community- based TB control program

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 7 DOTS and FIGHT approaches Political commitment with increased and sustained financing Case detection through sputum smear microscopy examination Standardized treatment with supervision and patient support An effective drug supply and management system. M&E system and measurement DOTS implementation. Capacity building for health staff Community knowledge, skill and behavior Monitoring, supervision and evaluation Networking and advocacy Resources mobilization Food aid component (discontinued since April 05) Micronutrient research

Assisted areas 2000 to 2006 Districts HCsPopulationHCsPopulation Alor Dist 574, ,647 Kupang City 274, ,890 Kupang Dist 359, ,801 Rote Ndao 246,889469,554 TTU Dist 469, ,345 Total 16324, ,237

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 9 Changes in district TB budget (US$) DistrictsYear 2006Year 2007 %  Alor DistrictN/A Kupang City % Kupang District5, , % Rote Ndao % TTU District1, , % TOTAL7, , %

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 10 Case Notification Rate (xx/100,000)

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 11 Sm+ cases detected (total 2,859)

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 12 A TB patient’s profile: Mostly poor Low educated – did not finish elementary school Low nutrition intake (only Kcal / day) Self medicates first with traditional medicine Knows the disease can kill – but doesn’t know the treatment is FREE Slow to seek health services (12 weeks delay from the first symptom)

Dist Chief/LGU/Planning Dept HCs / Private Clinics NGOs, CBOs, FBOs, etc. Village Leadership Community/Self-Help Groups TB patient & family 13

Health Center Mobile HC Village Midwives Sub HC

Health Center Government officers Church Self-help groups Traditional leader Health Cadres

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 16 NTT Governor Piet A. Tallo, is giving Category 1 TB drugs to a TB patient treated in Prof. Dr. W. Z. Johannes Provincial Hospital in Kupang, symbolizing the launching of Johannes DOTS Center on the National Health Day 12 November 2005.

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 17 Some lessons learned from the field Show them that you care! Benefits of home visits for treatment compliance and supervision – also for contact tracing. Stress your rules! Patient signs letter of agreement to comply with the treatment regimen Give testimonies! The most effective promotion is the one given by ex-TB patient Give testimonies! The most effective promotion is the one given by ex-TB patient

Involve other parties Obtain religious institutional support in TB treatment and case detection. Invest in TB prevention in schools as public health investment for the future. Be creative and eye- catching. Audio visual promotion method  more appealing to community.

Our vision for every child, life in all its fullness, Our prayer for every heart, the will to make it so. 19 Using TB patient’s photos (by permission) as advocacy tool. Identifying influential leaders  to help mobilize community and to improve participation. Identifying influential leaders  to help mobilize community and to improve participation.

Don’t be afraid to change! Open and intensive communication  anticipate reaction to an unpopular decision. (eg. discontinuing the food aid and incentives). Inappropriate knowledge about the disease  stigmas  hinders case finding, treatment and patient’s monitoring activity.

Ms. Esther Tabusan, 18 y.o. Before After

Mr. Urfinus Sa ’ u, 53 yo At the beginning And 7 months later …