Current status of integrated community based TB service delivery and the Global Fund work plan to find missing TB cases

Mozambique

Jorge Jone

Background • At moment we don't have a focal point in the program to

coordinate Community activities with different stakeholders.

• Some districts in the country remain without community partner;

• National coverage of community based TB activities in terms of TB basic management units (BMUs) is 86%.

CCS – 65 districts (42%);

CTB – 68 districts (44%)

• National coverage of recording and reporting of community based TB in terms of TB BMUs is 100% of the districts.

Key community stakeholders with coverage

Government/NGO/other CSO

• The government is not a community implementer. The work is done in partnership with community based organizations.

Implementation mechanism

• Usual the system is due to sub agreements or subventions with implementing partners at provincial and district level, providing all technical and financial/logistic support

• Resources to support community based activities is 15,7% of the total grant

• In all the provinces we have at least one of the following type of CHWs: Activists/PMTs/APEs/Volunteers. We have the activists where implementing partners are.

• The country pays an amount ranging between 60 to 100% of the national minimum wage.

Support for implementation

Support from national TB programme:

• Community DOTs strategy are being updated to support community implementation activities.

• Training/capacity.

• supervision by the district supervisor.

• Coordination meetings at the district level (monthly) and provincial (quarterly) on: Data monitoring and performance evaluation of community activities;

Management of the patient

Collecting of TB drugs for community DOTs.

Implementation tools

National guidelines for community based TB activities: DOTS National strategy

Implementation tools

Implementation tools

Monitoring and evaluation

NTP_CENTRAL LEVEL

Compile data from the provinces into a

national resume (Excel sheets);

Check SISMA (DHIS2) for any

discrepancies.

PROVINCIAL LEVEL

Compile data from district into a

provincial resume;

Check data in SISMA (DHIS2) for any discrepancies.

DISTRICT LEVEL

Compile the information and

send the forms to the provincial level;

Enter data into SISMA (DHIS2) per

Health facility.

HEALTH FACILITIES

Data collection from the primary sources and submit to the

District level

The DHIS2 is currently in use. The paper based system is not yet abandoned but by from the second quarter of this year we shall only use the DHIS2.

The compliance to the DHIS2 is very high with 98% of the District entering data regularly.

Monitoring and evaluation Descriptions

Data elements TB notification all forms by sex and gender; TB on vulnerable population groups; Community contribution; MDR-TB notification; TB/HIV; Treatment outcome (all forms TB, MDR-TB and

TB/HIV; TB Screening and contact tracing; Resources.

New TB case notifications Our collection tool do not disaggregate new cases from other cases

Treatment success Our tool collects data on those who concluded treatment successfully in the community (cannot tell who were from community referral cases)

Others We collect the contribution of each type of CHW for the TB

MDR-TB treatment in the community

Integrated TB service delivery

Mechanisms to support integration

• The activities are jointly (NTP and community implementers) planned and implemented in a complementary way. Ex: The NTP provide all the technical orientation and supplies (masks, sputum collecting bottles) and the implementers support logistics aspects.

• At the provincial level quarterly meetings are held in which responsible from programs at Provincial Health Directorate discuss and coordinate activities with all stakeholders .

• The NTP supervisions are integrated and include both clinical and community areas.

• Joint data validation exercises take place every quarter at the province level with NTP district and provincial supervisors, DOTS implementers where all registers are checked and data validation is conducted.

Mechanisms for coordination of community based TB activities

• There is a formal coordination mechanism such task forces for TB/HIV at provincial, district and Health facilities levels

• The key functions of this group is to discuss and coordinate all the activities, trainings, supervisions, M&E tools, lab issues, tests, reagents and drugs.

• The meetings are held monthly or extraordinary meeting when its necessary

• Implementers provide technical and logistic support for the meetings

Challenges, Bottlenecks and Solution

Challenges Bottlenecks Solution

Coordination

Insufficient coordination of community activities from NTP central level

Lack of a specific FP for community activities

Identify Community FP within NTP; Revitalize the technical working group and coordinate all community issues

Service delivery

Insufficient funds to cover all areas with community activities

Insufficient funds and stakeholders to support

Advocacy for additional funding

Monitoring and evaluation

Data quality Weak coordination with other implementers

Insufficient human resources at all levels

Revitalize the technical working group mentioned above.

Success story

CTB in Tete province is supporting Patients groups (GAAC’s) of 4 to 6 members each to reduce costs of transportation and demand at health facility level. • One patient member from each group goes to health facility for

consultation and collect drugs for the rest of the members in his group in a weekly basis.

• In the following week another member from the same group do the same.

This approach allows that during the second phase of treatment, the patients receives drugs at community level and from time to time they go for clinical check and collect drugs.

• They also promote educational sessions and patient to patient support

sharing there own experience within their families, intake of drugs, side effects, stigma.

• From January to march CTB has formed 29 GAACs for TB with 118

members in total.

Results 2015 2016 2017

Contribution of community referrals of presumptive cases to TB notifications

9% 21% 25%

Treatment success / default/death rates

Success: 89% Default: 4% Death: 5%

Success: 88% Default: 3% Death: 6%

Success: 90% Default:3% Death: 5%

Treatment MDR-TB success rate

47% 50% 47%

Country work plans for community based TB activities

Country work plans for community based TB activities (1/2)

• CCS (Collaborating Centre for Health) is a Mozambican non-profit organization;

• CCS was established in 2010 as a local partner of MOH;

• CCS is the new civil society PR for TB

Country work plans for community based TB activities (2/2)

• Stated objective – To Contribute to the TB

tipping point and end of AIDS epidemic in Mozambique by 2030

• Key stakeholders for implementation – NTP at all levels

– Sub-Recipients • Aga Khan Foundation

• Pathfinder International

• CCS

Reinforcing the National HIV and TB Response in Mozambique

• Implementation for 6 provinces (out of 11)

– TB BMUs covered by current GF grant - 65/153 (42%)

TB component (MoH and CCS) US$ 45,278,988

Matching funds US$ 6,000,000

Fund allocated for community based TB activities (CCS)

US$ 7,088,947

CCS community based TB activities

• Community Based DOTS (CB-DOTS) – CCS will train activists to implement a standardized package for

community TB;

• CCS will design and Implement Sputum transportation system in the 6 selected provinces – At intra-district level, activists will collect sputum samples at household

level and send the samples to HF´s with GeneXpert or microscopy for TB diagnosis

– Samples for culture and DST will be transported from districts to provincial level.

• Community dialogues will be conducted – TB and HIV literacy, – TB, treatment, retention and adherence, – Access to health care and issues of stigma, discrimination and their

solutionsTargets

Country work plans for community based TB activities

Country specific opportunities

• Opportunities to increase community engagement to achieve targets listed on previous slide

• TB screening in prisons (expand the training of correctional officers on health issues for TB);

• TB screening in schools;

• Creation of a Community national system

• Engaging miners association groups, traditional healers association, groups of ex-Tb patients and different vulnerable populations groups.

Anticipated implementation challenges and suggested solutions

Challenges Solutions

Weak HF demand response created by Community level screening

Strengthening the coordination

Screening quality of CHW and quality of samples taken at the community level

Training, mentoring and regular monitoring regular of the activities

Effective implementation of the system of transport of samples

• Expansion of the laboratory network • organization of the community system

for better coordination

Return of laboratory results to community Use of bikers for returning of the results to the communities

Obrigado Thank you