1. Integrating TB in the Workplace Presentation by: Miss. D.M.Nokwe 15 th of October 2009 TB Directorate

2. Acknowledgements National Department of Health URC(USAID) CSIR WSU Pro Health Risk NHLS PERCCI 2

3. DOH Partners Pro Health Risk ECIPA,Siyakha,UDIPA WSU URC PERCCI Wellness task team 3

4. Context  South Africa has the 2 nd highest TB burden in Africa and 5 th highest in the world  Around 70% of new TB cases are HIV positive  2% of new TB cases and 7% of retreatment cases have MDR-TB  Majority of patients seek care in the private sector and traditional health practitioners before presenting to the public sector 4

5. Context (Continued)  TB, TB/HIV and M(X)DR-TB has a high burden of disease against a background of poverty and financial crisis  Eastern Cape is the second largest Province of South Africa which has a very high burden of TB (all pulmonary cases): Over 60 thousand new TB cases occurred in EC in 2008 5

6. Context The Cure rates for Q1 of 2008, 59,6% Defaulter rate is 9,2%. The province will complete clearing the backlogs end November. These Outcomes are far from achieving the MDG’s, hence the engagement of the private sector Disclosure at work is a problem due to fear of stigmatisation, discrimination and loss of employment resulting in high rates of treatment interruption and or defaulting Poor access to services and lack of money for transport

7. Objectives Raise awareness about TB Improve Infection control Increase case finding Access to TB treatment Promote Treatment adherence and compliance Standardize TB treatment to NTP 7

8. Process VW in Uitenhage has a best practise model of TB in the workplace. The Clinician and the Occupational nurse were trained on TB, TB/HIV and STI management All the registers that are used by VW, are provided by the department Drugs and NHLS, are the responsibility of the department The department conducts quarterly reviews of the TB Programme using the DRAT Tool 8

9. Process The department and VW, conduct joint awareness campaigns This programme is doing very well as they have good outcomes, cure rate ranges between 98% to 100%. The occupational nurse attend the district meeting in order to discuss such things as, referral Pathway, management of contacts and others.. 9

10. Process Awareness campaigns has been conducted in 20 companies in the NMM 2 Companies have started with screening which was provided by DOH, e.g. Ford 10

11. TB awareness and TB screening Ford motor company

12. Process The Directorate made a presentation to the executive members of the House of Traditional Leaders Several meetings were held to discuss how the Traditional Leaders are going to work with the Department of Health The TB Directorate conducted training on TB, TB/HIV for 450 Traditional Leaders The Executive members for IYA(Imbumba Yamakhosikazi Akomkhulu) were also trained on TB and TB/HIV 12

13. Process Currently, both Traditional Leaders and IYA, are leading awareness campaigns on TB, in their communities The traditional Councils are used as treatment points, this helps to improve access to services IYA developed a clear action plan on how they are going to implement the programme The department has developed an M&E framework to monitor the plan 13

14. Private General Practitioners The department of health has established Public Private Mix with the General Practitioners at the Nelson Mandela Metro The Private GP’s submitted a proposal to the TB Directorate as well as Walter Sisulu University, about the establishment of the PPM Project The two proposals were not mutually exclusive, hence the department agreed on a tripartite arrangement 14

15. Process (Continued) It was agreed that, the department of health will be the custodian of the project and oversee implementation process Walter Sisulu will provide academic support, operational Research and Evaluation at the end of the project The Private Practitioners will be the implementing partners. A memorandum of understanding and individual agreements were developed There are Pre-requisits for starting the PPM 15

16. Process CSIR, conducted Risk Assessment to 6 GP Clinics 20 Doctors were trained on TB, TB/HIV &STI, Infection Control, Clinical Management of M(X)DR-TB and PULSA plus(Practical Approach to Lung Health plus HIV&AIDS) and Recording and Reporting 10 GP’s have signed the individual agreements On the 8 th of June 2009, implementation of the project started. Currently, there are 46 patients managed by the GP’s 16

17. Generic Package of care VCT with rapid HIV testing to all TB. Early diagnosis and treatment of TB in HIV+ Isoniazid Preventive Therapy (IPT) for HIV+ Cotrimoxazole Preventive Therapy (CPT) Effective Case Management, Tracing and Management of Contacts Formalized referral systems

18. Process The department of health is providing drugs to the GP’s Laboratory specimen sent to NHLS, but paid for by the department GP’s have got all the records needed for the TB management, including the notification book Ongoing training and GP recruitment Private hospital groups approached for participation-with keen interest to participate 18

19. Role of DOH Conduct sensitisation workshop with business quarterly Conduct training on TB workplace policies. Conduct training of occupational health practitioners on TB Conduct joint awareness campaigns in commmunities Monitor and evaluate the implementation of workplace TB programmes.

20. Roles of the stakeholders Conduct on going awareness campaign at the workplace. Screening of suspects and periodic screening for other employees. Workplace DOT programme, to improve adherence to treatment Ensure implementation of infection control guidelines, e.g. Availability of infection Control plan in the workplace to adree issues of Open Window Policy, Cough hygiene

21. Challenges Mobility of patients-stigma Policy, Human Rights and ethics(XDR/MDR) Inadequate financial and human resources Management of contacts Employers, who do not understand, hospitalisation of a patient for a long time especially M(X)DR-TB Infrastructure of some of the companies does not comply to infection control measures. 21

22. How they were addressed The GP’s and VW are using a referral letter that is used by the department Continuous awareness campaigns Due to inadequate funding the department is also supported by NGO’s in implementing these projects, like URC. The department has encouraged the employer to communicate the Leave policy to the employees and ensure that policies addressing confidentiality and discrimination are available

23. How they were addressed The department has supplied posters on cough hygiene, so as to remind the employees about Cough Etiquette. 23

24. Lessons learnt There are more benefits than risks in the PPM Public and Private can work together in the fight against TB, by improving access to services in the workplace TB workplace programme helps in improving adherence (DOT) and reducing absenteeseem. Sharing of resources for the benefit of the patient

25. Outstanding Risks and Issues Management and coordination Stakeholder relationships, expectations & Change Management Funding and Sustainability Infection Control Exposure Risk NHLS & Drug Supply Case Management, Tracing, M(X)DR-TB 25

26. Way forward Bridge the gap between, two worlds two cultures-public -private Scaling –up of TB PPM services in private sector. Engagement of private providers in intervention for: Programmatic management of TB-M(X)DR- TB in communities, –EPTB -TBHIV co-infection diagnosis and treatment, 26

27. CONCLUSION STOP TB... COMPLETE TREATMENT!!! 27

28. THANK YOU ENKOSI