Community TB Care: a global review

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Community TB Carea global review
Community Participation in TB and
TB/HIVaddressing bottlenecks for
scale-upVersailles, Palais des Congrès16th
October 2005
gargionig_at_who.int
Dr Giuliano GargioniStop TB DepartmentWorld
Health Organization - Geneva
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Overview

• What is Community TB Care
• Rationale for its inclusion in NTP strategy
• Specific objectives of CTBC
• Operational approach
• Global review of good practices
• Preliminary findings

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What is Community TB Care (CTBC)

• Operational partnership between the health
  services and civil society aimed at contributing
  to health promotion,
• TB prevention care.
• Responsibility for TB control remains with the
  NTP.
• Patient, family and community education
• Case detection (referral of pts with chronic
  cough)
• Support to patients (DOT) throughout treatment
  until cure
• Advocacy for political commitment to TB control
• Increased accountability of local H.S. to
  communities

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Rationale for CTBC initiatives
Concentration of health facilities in and around
urban settingspoor accessibility (geographic and
economic) for rural based populationHospitalizat
ion of TB patients, often unnecessary, is costly
for Health Services and imposes a further direct
and indirect costs on patients and their
families.Poor access prevents TB patients from
attending regular follow-up ? poor adherence,
interruption, transmissionPoor perception of TB
as a public health problem.Poor (or late) case
detection CTBC addresses these
constraints through social mobilization and
patient-centered care
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Stop TB strategy and CTBC

• The foundation of the Stop TB strategy is
  effective patient care which alleviates
  suffering, as well as controls and prevents TB in
  a community
• CTBC Improved access to services ("supply")
  promoting community participation and action (1)
  to increase demand for proper care and (2) to
  foster participation in patient's care
• Promoting co-responsibility for health. Most
  people in need of treatment for TB and HIV live
  in resource-limited settings scarce resources
  should be allocated to functions and components
  of care that are strictly medical, encouraging
  the civil society to take up, whenever possible,
  the responsibility to support patients.

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Specific objectives of CTBC

• To foster community's co-responsibility in
  addressing TB as a public health problem.
• To improve referral of TB suspects by communities
  to diagnostic services.
• To improve access to TB diagnosis and treatment
  through community participation in patients'
  support and provision of DOT.
• To reduce financial burden for patients and their
  families, reducing duration of hospitalization
  and number of daily and follow-up visits to
  health facilities.

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Operational Approach

• Strong ACSM approach needed awareness of TB as a
  public health problem paves the way to earlier
  referral of TB suspects and proper care and
  support of patients. Recurrent issues
• Community
• Partnership or co-responsibility vs. mere
  geographical extension of services
• incentives and/or empowerment (e.g. eradication
  vs. long term control)
• creation of capacity / responsibility as a
  positive externality
• Family / Patient / Volunteer
• DOT accepted as support to the patient
• simple functions, nobody is medicalised
• Affordability, acceptability for the patient

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TB and TB/HIV controla social pact beyond the
health systems?

• The value of this partnership between government
  services and the community goes beyond its
  operational returns (technical, administrative,
  economic, health, etc).
• It is a social pact, which strengthens both
  partners.
• Moving beyond the biomedical concept of DOT and
  treatment adherence and integrate these in a new
  paradigm of solidarity and support to the
  patient.
• Can health services cope with continued
  monitoring of adherence of millions of people on
  ART for life?

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WHO global review of CTBC initiatives

• Under the definition of "CB", a wide range of
  promising initiatives. Need for a clear
  terminology.
• Need to learn lessons from good practices.
• What are the essential elements, beyond the
  specificity of the context?
• Is CTBC a mere re-organization of the health
  services?
• How and Why does it work? The need for a mixed
  quantitative/qualitative method of assessment

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Countries included in the reviewor where T.A. is
planned for CTBC implementation

• SEAR review Bangladesh, Nepal
• T.A. India, Thailand, Timor Leste
• WPR review Philippines, Cambodia
• T.A. Vietnam (ethic minorities in remote
  areas)
• AFR review Uganda, Malawi, South Africa-
  West/East Cape
• T.A. Ethiopia, Burkina Faso
• 31 countries have implementation plans
• Synergies with TB/HIV and PPM
• AMR review Mexico, Colombia
• T.A. Brazil (comm care already in place for
  HIV/AIDS
• targeting Indian communities and
  rural areas)
• EMRO review Pakistan (lady health worker)
• T.A. Sudan (currently Kartoum peri-urban)?
• EURO T.A. addressing special communities and
  marginalized groups
• of TB patients (e.g. prisoners, alcoholics) in
  Russian Fed.

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General Plan of Work

• Completion of Review of good practices by
  mid-2006 Publication of case-studies and
  recommendations.
• Intensified technical support to 20 countries
  during the biennium '06 - '07 (funds to start-up
  initiatives available mostly through GFATM and
  bilaterals).
• Support, through the Stop TB Partnership, to T.A.
  provided globally by partners establishment of a
  Task Force on Community TB Prevention and Care
  (Mexico City, Sept 2005)

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Preliminary Findings (UG, BAN, MEX) - 1

• Effective ways to establish CTBC
• Direct operational partnership between the health
  services and the community to improve patient's
  support and quality of care (Uganda)
• Partnership between government and NGOs
  deep-rooted at community level (Bangladesh)
• Strong ACSM approach awareness of TB as a public
  health problem, early referral of TB suspects and
  proper care and support of patients ? targets
  achieved! (Mexico)

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Preliminary Findings (UG,BAN, MEX) - 2

• Motivating factors
• Voluntary work of treatment supporters sustained
  by social solidarity and commitment to community
  welfare (Uganda)
• Community workers improving their social status,
  serving the poor, bridging government services
  and communities (Bangladesh)
• Strong social awareness and commitment to promote
  community health, empathy between health staff
  and people, public acknowledgement (Mexico)

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Work in progress

• The potential impact of CTBC, meant as
  participation of civil society in TB control, is
  very large.
• It improves equity in access to health services
  and provides more adequate support to patients.
• NTPs should design with communities/patients
  models that are effective and sustainable in the
  long term.
• WHO and partners committed to document which
  approaches have been working better and why.
• Motivational aspects are key factors for a
  community to sustain its commitment. Building
  motivation requires adequate commitment, and
  should influence the approach to establish CTBC.