Decentralisation as a Strategy to Address Major Challenges of DOTS Services: Experience of Kano State, Nigeria

Mahmoud Nasir Mohammed 1, Tijjani Hussaini 1, Jibrin Sani 2, Sokpo Emmanuel 2, Ray Tushar Kanti 3 & Dacombe Russell 3

1: State Tuberculosis and Leprosy Control Office, Kano, Nigeria.2: Nigerian Partnership for Transforming Health System. 3: Liverpool Associates in Tropical Health.

Aim: To take TB services closer to communities so that each political ward in the state has at least one health facility offering TB services.

Background: Kano is one of the 36 states that make up the Federal Republic of Nigeria. The State has a population of 9.9 million people spread across 44 Local Government Areas (L.G.A.), 483 wards and more than 10,000 villages. Health care service in the state are provided through a network of Primary Health Care (PHC) clinics, secondary and tertiary health care centres. In total there are 1001 public, 202 private and 2 tertiary health facilities in the State. The State started implementing TB services based on the Directly Observed Treatment Short Course (DOTS) strategy in February 2003 in 5 L.G.As and by the end of 2007 the programme had expanded to 25. Most of these TB – DOTS service points in the L.G.As are situated in secondary health facilities which serve as both treatment and microscopy centres. Often, however, people have to travel from all over the LGA (distance up to 50km or more) to access services. These TB – DOTS service points are supervised by Local Government TB and Leprosy Supervisors (LGTBLS) provided with a motorcycle to coordinate all TB and leprosy (TBL) activities in their respective L.G.As. Since the commencement of DOTS implementation in 2003 new smear positive case detection has been low (ranging from 11.3% to – 19.3%) while treatment success rate is relatively high (67.15% to 72.0%) but not up to the global target of 85%. The table below gives a summary of the states essential TB indicators.

Table 1: Kano State TB indicators from 2003 to 2008

Methods: 5 L.G.As were selected to pilot decentralisation using the following .criteria:

1. The L.G.As which were the first to start TB DOTS implementation and ..hence have an established system . 2. Those which had a network of health facilities to expand DOTS ..services to.

In each of the selected L.G.As Primary Health Care Departments .developed specific LGA micro plans for decentralisation with support .from the state TB .programme. The micro plans detailed health .indicators, health infrastructure, community structures and the location .of potential DOTS facilities based .on identified criteria and the process .of supervision. Following the development of the micro plans a total of .51 health facilities were selected. These .facilities were geographically .spread across the Local Government and supervised by LGTBS.

Two DOTS providers were trained in each of the 51 centres while all .other health workers in these facilities were sensitised on the signs and .symptoms of .tuberculosis to help refer patients for sputum microscopy. .Patients visited the clinic (about 3- 4 km) for a supervised daily dose for .the first .two months of treatment and once a month for the remaining .six months of treatment .

.As part of advocacy communication and social mobilisation (ACSM) .activity, Patients – Provider – Community Interaction (PPCI) meetings .were organised .to bring all stake holders involved in the management of TB patient to interact and to sensitise the general community.

Case Detection RateThe case detection rate for the five selected LGAs (decentralised LGA) before (January to December 2006) and after (January to December 2007) decentralisation is shown in the table below:

Table 2: Smear positive case detection rates for the five selected L.G.As before decentralisation (January to December 2006) and after decentralisation (January to December 2007)

Table 2 is graphically represented right:-

1. New secondary health centres that were opened in neighbouring LGAs that previously ……..accessed treatment in these selected L.G.As 2.Shortage of intensive phase drugs in Nigeria and Kano State thus limiting the number that can be put under treatment.3.Due to acute shortage of anti TB drug in Nigeria as well as Kano during the study period case detection and case registration was almost stopped for about 4 to 5 months which had a direct impact on case detection number.

Cure Rate:Cure rate for cases registered for treatment before decentralisation (January to December 2006) and after decentralisation (January to December 2007) is shown in table 3 below:-

Table 3: Cure Rate for Sputum Smear Positive Case Registered before decentralisation (January to December 2006) and After Decentralisation (January to December 2007)

Table 3 is graphically represented below:-

It can be seen from the graph that cure rate before decentralisation (between January and December 2006) is 57.14% far lower than the global target for TB control. This could be attributed to:-1. The fact that patients needed to travel over great distance with the cost of transport (average of 1$) more than the daily income of most patients (an average of less than 1$ day).

However after decentralised there is remarkable improvement in cure rate (78.76%) of patients registered after decentralisation which is close to the global target (though only the result of two quarters can be obtained). This increase could be attributed to:-

In 2005 stakeholders involved in TB control developed the State TB strategic plan by Kano State Tuberculosis and Leprosy Control Programme (KNTBLCP) with technical support provided by Partnership of Transforming Health System (PATHS). It was during this process that it was realised there was need to decentralise TB services to primary health care facilities in the State if global targets for both case detection and cure rate were to be achieved. The process of decentralisation started in November 2006 with the first primary health care centre offering DOTS in January 2007.

1. Ease by which treatment can be monitored 2. Reduced distance travelled by the patient 3. Increased awareness of other health workers in these primary health centres on requesting for follow up sputum smear examination 4. Involvement of families and communities in treatment through PPCI.

Defaulter Rate:Default rate for smear positive cases registered before and after decentralisation is shown in the table below:-

Table 4: Defaulter Rate for Sputum Smear Positive Case Registered before decentralisation (January to December 2006) and After Decentralisation (January to December 2007)

Table 4 is graphically represented right:-

It can be seen that there is high defaulter rate in the period before decentralisation reaching a peak of 26 % in quarter 2. The trend decreases from quarter 3 onward though it remained high (above 5%). This high default rate can be attributed to:- 1. Distance travelled by patient to access treatment (can be as far as 30km to 40km)2. Cost of transportation (can be as high as 1 – 2 $) which is not affordable by most of the patient.

However, there is significant decrease in the defaulter rate after commencement of decentralisation. This could be attributed to:-

1. Reduced distance travelled by patients for supervision of treatment 2. Greater involvement of health workers and community during treatment.

CONCLUSION: TB services being brought closer to these communities has resulted in increased cure rate and reduction in defaulter rates though a marginal decrease in ………………… case detection rate was observed.

N

H/F

H/F

H/F

H/F

H/F

H/F

H/F

H/F

H/F

Lakwaya

MainikaD/fada

Kutama

Badari

Kara

Getso

S/Birni

Madadi

GNH

H/F

KEY

SECRETARIAT

HEALTH FACILITIES

DIRECTION OF COMING

BACK FROM

SUPERVISION

DIRECTION OF GOING

FOR SUPERVISION

Gwarzo Local Government Map showing tour chart

Weekly fixed tour calendar of TBL Supervisor

Note: TBL supervisor originally travelled once in a month to provide MDT (for leprosy patients). After the introduction of decentralised DOTS a weekly travel plan was developed to cover all treatment/DOTS centres once a week which is one of the biggest shift towards intensive supervision.

It can be seen that case detection rate in the period before decentralisation case detection is marginally higher in 2006 generally (period before decentralisation). This decrease in case detection rate after decentralisation could be attributed to:-

Result and Discussion: Health facilities referring patients for sputum microscopy increased from one centre per LGA to at least 8 in all the LGAs and patients travelled less than .4 km to access services.