Current status of Integrated Community Based TB Service Delivery &

Global Fund Work Plan To Find Missing TB cases

In Myanmar

Background

TB Situation in Myanmar

TB is a major public health problem

One of the world’s 30 high TB burden countries

30 high MDR-TB burden countries

30 high TB/HIV burden countries

Source: Global TB Report (2017) Rate (per 100,000 population)

Estimated incidence 361

Estimated TB Mortality (excludes HIV+TB)

47

Estimate TB Mortality (HIV+TB only) 9.3

Estimate Incidence (MDR/RR-TB) 25

MDR-TB among new TB patients (3rd DRS, 2012-2013)

5.0%

Milestones of Community Based TB Care Activities

• In 2007, with the support of 3DF, implementing partners started the community based

TB care activities in selected townships. No reports received in NTP.

• Draft guideline for community based TB care developed together with implementing

partners and technical support of WHO as an out put of workshop conducted on (4-9-

2010). Revised guideline on 2014 (English version) and 2015( Myanmar version).

• JICA implemented the pilot project for Community Based TB Care Activities in

Pyinmana Township

• To improve TB control activities in unreached areas, NTP is engaging with Local

NGOs in Community Based Care Activities in 2011. Community Based TB Care

Activities are starting since 2nd Quarter 2011.

• TOT training given to 4 local NGOs in Naypyitaw in 2011. Refresher training also

given every 2-3yr.

• Yet, the four local NGOs ; MMCWA, MWAF , MRCS and MHAA are implementing the

Community Based TB Care Activities in States and Regions.

8-03-17 4

ROLE & OBJECTIVES OF CBTBC

General Objective

• Involvement of community in TB prevention and care activities for reduction of TB disease burden in community

Specific Objectives

• To improve TB case finding

• To empower community for health thr: TB care

• To improve case holding

• To increase community awareness about TB

National coverage of community based TB activities

Year No. of townships with CBTBC

(*for township under TB funding scheme)

No. of reported

townships

Percentage of townships with

CBTBC

2014 201 319 63%

2015 221 319 69%

2016 235 320 73%

2017 276 321 85%

2018 242 321 75%

Key stakeholders for implementation

Local NGOs International NGOs

Myanmar Women’s Affairs Federation Asia Harm Reduction Network

Myanmar Maternal & Child Welfare Association

International Organization for Migration

Myanmar Medical Association International Union Against Tuberculosis and Lung Disease

Myanmar Health Assistants Association Malteser International

Myanmar Red Cross Society Medical Action Myanmar

Pyi Gyi Khin Population Services International

Ethnic Health Organizations (EHOs) World Vision International

Karen Department of Health and Welfare

Health Poverty Action

EHO – Special Region 2 Burnet Institute

EHO – Special Region 4 RIT/ JATA (Japan Anti-Tuberculosis Ass.)

Community Partners International

Geographical Coverage of stakeholders (2018)

Stakeholders No. of townships

Local NGOs Total 170 townships of 13 states/ Regions

International NGOs Total 166 townships of 15 States/ Regions

Both Local NGOs & INGOs Total 242 townships of 15 States/ Regions

Total 178 townships of Naypyitaw and 13 States/Region (55%) are covered by current GF grant.

Key community stakeholders with coverage

Implementation & Integrated TB Service Delivery

Activity Responsible Organization/ Person

Conduct situational analysis Implementing Partners (IPs)

Establish partnership & coordination mechanism

Township health committee & IP/all stakeholders

Capacity building

Dissemination of training materials NTP at Region/State level

Training NGOs, Township health staff with technical support from NTP

Infection Control All health workers

Advocacy, Communication & Social Mobilization

Key stakeholders, NTP, TMO, IPs

Supervision and M&E

Organize CBTBC team Led by TMO, IPs & local authorities

Regular S&M Joint supervision, NTP, TMO and IPs

Quarterly Review Meeting TMO, BHS, TB Coordinators, Volunteers, focal from IPs and local authorities

Implementing cadres and their geographical coverage

Cadres Geographical coverage in 2018

Community Health Volunteers (CHVs) 205 townships of 15 States/ Regions

Integrated Community Malaria Volunteers (ICMV)

48 townships of 4 States and 3 Regions

MDR-TB treatment supporter 65 townships of 3 States and 5 Regions

Drug seller 50 townships of 1 State and 6 Regions

Salary, Incentives and Other enablers

• Transport allowances and/or incentive payments for specific results

(referrals, notifications, treatment success)

• Financial incentives for DOT provision especially in CB MDR-TB Care

• Regular meetings and training & certificate of appreciation

• logistical support for volunteers such as health education materials,

infection control tools and implementation tools

• Recognition, acknowledgement and motivation by service

Referral mechanism of presumptive TB

Health talk in the

community

(special outreach program)

Identify presumptive

TB cases

Refer to township TB center (or)

sputum collection & transportation to

township TB center

- Diagnosed TB cases registered at township TB center

- DOT provision by volunteer

Implementation Tools

NTP Field level

Sputum request form Township CHV register

Township TB laboratory register TB Presumptive referral form from CHV to Township Health Centre

Tuberculosis Treatment Card TB register for CHV

Township TB Register Monthly report form for CHV

Quarterly report on TB registration [TB-07]

Monthly report form for Supervisor on CHV

Quarterly report on the outcomes of TB patients [TB-08]

Supervisor registry form

Monitoring and Evaluation

Monitoring and Evaluation

• Myanmar adopted WHO recommended core indicators.

• Standard & Benchmark analysis on TB Surveillance was done in collaboration with WHO and RIT in 2014 and 2017, showing the progress of the system.

• In 2014, MoHS began using DHIS2 for processing its data at the national level. Currently all township level data are entered at State/Region level. NTP planned to expand to the township level in 2nd quarter 2018.

• However, paper base system with aggregated data is still a main reliable tool to develop quarterly and annual TB report though DHIS2 began to function to have basic TB information in parallel.

Monthly Reporting

Monthly Reporting

Quarterly Reporting

Quarterly Reporting

Data collection & flow structure

CHV supervisor

CHVs CHVs

Township NTP/THD

CHVs

Central NTP

State/Regional NTP

Data Elements collected Number of townships adopting CBTBC

Number of CHVs trained in the program

Number of CHVs actively involved in the program

Number of presumptive TB referred by CHVs

Number of TB cases (all form) notified among presumptive cases

Number of TB patient receiving DOT through CHVs

Number of TB patients who received patient support

Number of patient completed TB treatment among patients availing DOT from CHVs

Number of HE sections and attendees

Number of supervision visit by community supervisor

INDICATORS

• Number of presumptive TB referral

• Number of all forms of TB cases notified from community based activities

• Percentage of notified TB cases (all forms) contributed by non-NTP providers – community referral

Success Story

Success Story: CBTBC model & outcomes

• A model for CBTBC was developed and piloted at Naypyitaw-Pyinmana Township, in collaboration with JICA project in 2011.

• After 18 months, the project showed good outcomes with regard to system development and case finding.

• For community-based TB care to be successful, not only commitment of CHVs in the communities but also the participation of all the health and administrative staff working for the communities together with community people are important.

SOURCE: Guideline for community based TB care to increase access to quality DOTS service , Myanmar, 2011

Success Story: Patient-Centered Community-based MDR-TB care &

treatment support model

• In 2015-2016, 3 Local NGOs implemented CB MDR TB care & provided evening DOT to 81% (1656/2053) of MDR TB patients in 37 townships of Yangon.

• CHVs provided HE and adherence counseling to patients & contacts, and referral services.

• Qualitative study showed that both patients and BHS appreciated adherence counseling & evening DOT, &

it was recommended to expand CB MDR TB care while HR at public health sector is limited.

[Saw et al., 2017]

RESULTS

Trend of National TB Case Notification (1994-2017)

17

41

0

21

16

1

24

16

2

27

44

8

30

16

4

36

54

1

40

24

4

42

58

8

41

24

8

41

38

9

42

31

8

42

33

2

42

91

0

42

59

5

50

18

8

48

82

5

51

41

6

49

55

0

18

44

4 29

18

6 43

80

2 56

89

1

65

85

3

77

21

9

81

82

8

78

48

1

82

89

3

84

81

6

89

81

5

93

54

4

87

40

6

91

82

4

91

87

5

88

20

9

82

47

5

15

55

17

00

8

20

19

6

16

11

3

14

75

6

19

62

6

31

70

3

42

45

5 5

82

43

77

23

1

97

90

9

10

79

91

12

35

93

13

35

47

12

87

39

13

40

23

13

74

03

14

31

64

14

81

49

14

21

62

14

20

12

14

07

00

13

96

25

13

20

25

0

20000

40000

60000

80000

100000

120000

140000

160000

No

. of

TB P

atie

nts

Years

Bacteriologically Confirmed Cases Clinically Diagnosed Cases Total TB Cases

Trend of CNR (2011-2017)

286 293 279 276 271 266

250

98 98 97 97 94 98 93

280 272 258 249

217 207

192

-

50

100

150

200

250

300

350

2011 2012 2013 2014 2015 2016 2017

Cas

e N

oti

fica

tio

n R

ate

pe

r 1

00

,00

0

CNR (all form) CNR (bact. Confirmed) CNR all forms by routine PCF

Contribution of community referral to national TB notification

1% 6% 6% 7% 11% 14% 15%

0

20000

40000

60000

80000

100000

120000

140000

160000

2011 2012 2013 2014 2015 2016 2017

No

. of

All

form

s o

f TB

pat

ien

ts

Year

National (NTP + Other units) Community partners

22% 18% 22% 17% 15% 16% 14%

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

2011 2012 2013 2014 2015 2016 2017

All forms of TB Referral of CHVs

All forms of TB among presumptive TB referral of Community Health Volunteers

Proportion of Total TB cases contributed by NTP & Other Partners

(2017) (n=132,025)

NTP 85%

Local NGOs 5%

INGOs 10%

NTP

Local NGOs

INGOs

Country work plans for community based TB activities

Country work plans for community based TB activities

1. Policy and strengthening CBTBC Timeline Responsibility

a. National level policy development 2011 (guidelines)

MOHS (NTP)

b. National and local level advocacy meeting with stakeholders and political and health authorities

Annually NTP, Implementing partners

c. National level production of communication tools

Annually NTP, Implementing partners

d. CBTBC evaluation meeting Annually Implementing partners

Country work plans for community based TB activities

2. Capacity building Timeline Responsibility

a. National level consultation to review/endorse and get familiar with advocacy and communication plan and tools, HR development plan and tools and M&E indicators.

MOHS (NTP)

b. National level printing of training materials (with periodic revisions)

Annually NTP, Implementing partners

c. Training Annually for New & Refresher

NTP, Implementing partners

d. Systematic recording and reporting of the activities.

Quarterly State/Regional/township NTP, Implementing partners

Country work plans for community based TB activities

3. Support to community health workers and volunteers

Timeline Responsibility

a. Establishment of self-help groups and village-based support groups

Implementing partners

b. Provision of incentives for delivering services by CHW.

Annually NTP, Implementing partners

c. Engagement of volunteers in health talks, contact tracing, sputum transportation, presumptive TB case referral and DOT provision

Annually NTP, Implementing partners

d. Quarterly evaluation meeting with volunteers

Quarterly State/Regional/township NTP, Implementing partners

Overall budget for community based TB activities

Module Budget (2018-2020)

TB care and prevention 17,396,647

MDR-TB 3,079,924

RSSH: Community responses and systems 948,063

RSSH: Health management information systems and M&E 5,068,968

RSSH: Human resources for health (HRH), including community health workers

5,644,394

RSSH: Integrated service delivery and quality improvement 28,902

RSSH: National health strategies 2,681,026

Total Budget 34,847,924

Country specific opportunities

o A very strong TB-TSG under MHSCC with its highly functional technical wings (working groups) ensures strong coordination and national ownership.

o Strong collaboration of National program, UN agencies and CSOs o Inclusion of Ethnic Health Organization in TB care and prevention

o Integration of community based TB services to ICMV volunteers*

through capacity building (*in local context where it is applicable)

o Epidemiological review for better implementation of CBTBC based on findings of ongoing prevalence survey

Implementation Challenges & Suggested Solutions

Limited Human Resource in public health sector, at all levels

HR support

Frequent turnover of IP staffs and community volunteers especially in highly mobile and border areas

Selection of strongly committed volunteers, Timely replacement and refresher trainings

Accessibility of diagnosis and cost for referral

Health services reachable to the communities eg; TB mobile clinics

Social protection programs or policies

Uneven distribution of NGOs & Coverage of CBTBC

mapping and avoid overlapping

Thank you

ADDITIONAL SLIDES

Coordination

• Most NGOs engaging TB service are members of TB Technical and Strategy Group (TBTSG) under Myanmar Health Sector Coordination Committee (M-HSCC, expanded version of CCM).

• WHO is a secretariat of TBTSG. More than 30 organizations are participating in TBTSG regularly. The meeting was held 3-4 times a year.

• Regular coordination and meeting was conducted between National Program, PRs and SRs.

• However, NGO coordinating body should be formed at regional and state, and township levels. Regular meeting in township level has been budgeted in GF project.

Mechanism for coordination of community-based TB activities

Implementation Tools: National Guidelines for CBTBC

Implementation Tools: Health Education flip chart

Support for implementation

1. NTP is supporting case finding of CBTBC

a. by strengthening resources and capacity at referral township centers

b. Disseminating guidelines for CBTBC and Training module

c. Supervision and monitoring

d. Joint supervision visits, and monitoring and evaluation of reports

2. Capacity building and refresher training annually

3. Supervision from supervisors/ upper level

4. Monthly/ Quarterly monitoring and annual evaluation of CBTBC activities

Implementation Tools: Presumptive TB Referral Form

Implementation Tools: Monthly Report Form for Community Health Volunteers

Implementation Tools: Monthly Report Form for Supervisor on CHVs

Implementation tool to ensure treatment completion and patient support:

Treatment Card