Making it happen - Increasing access to diagnosis and treatment for tuberculosis

One third of 8.7 million cases of tuberculosis (TB) occurring each year are missed by health services and there is a need to increase case identification worldwide. In Ethiopia, TB is one of the major causes of adult death, affecting the lives of many people and health service coverage is poor, resulting in low case detection.

Recently, proactive approaches canvassing the community to identify individuals through house-to-house visits combined with health education have been shown to increase TB case detection. We have shown that village-based health extension workers (HEW) in Ethiopia increase the accessibility to diagnosis and treatment in the Southern Region. HEWs are part of the Ethiopian Health Service Extension Programme (HSEP), which aims to improve access to health services by providing basic health packages at community level. In the new TB package, HEWs identify individuals with symptoms suggestive of TB, collect and prepare tests from sputum and supervisors with motorbikes link the HEWs to the diagnostic laboratories and treatment is provided and supervised at home or at the local health post. The package has doubled the number of cases identified and increased treatment completion, confirming that bridging the gap between services and the community is crucial to increase uptake.

The approach has considerable support by health providers and donors and has generated interest for adoption by the HSEP. However, moving from an independent-project to a package integrated within the system is a process that requires many steps for adoption. Clearly there is a need to have a process to formalise the debate to consider the adoption of a community-based TB package and we therefore propose to:

1. Engage health and financial policy decision makers at district, regional, national and international level to discuss the process of policy development in Ethiopia,

2. Engage policy makers and programme managers to set objectives and agreeing monitoring and impact assessment needs for the TB package and

3. Document the process considering the implementation of the package within the HSEP as a case study.

Methods:
The process will start by preparing packages of documentation describing concepts and research findings; systematic reviews available; summaries of findings presented in ways accessible to political, health service and user audiences and users; descriptions of mechanisms to guide policy change and discussion guides with issues that need debate. We will organise a variety of discussion platforms of all stakeholders including focus groups discussions (FGDs) and in depth interviews (IDIs) with Ministry of Health (MoH), beneficiaries and programme implementers to highlight barriers to accessing diagnosis and treatment; staff from the Health Bureau and the department of finance and economic development to discuss the package, its advantages, disadvantages and costs; barriers, enablers and implementation modalities of best practice that could be useful to the community and IDIs with high level policy makers, the WHO and funders to discuss policy formulation. The process will culminate in a national meeting to discuss the package and eventual policy development.

Learning by doing
The barriers for accessing services are not specific to TB and similar approaches are needed for other health problems and Ethiopia is desperately looking for interventions to improve health service delivery for rural communities. The process of adopting a new package could be used to build capacity to review and develop policies and as a knowledge transfer platform for similar packages within the HSEP. The process proposed would be a catalyst for capacity building in decision making, the use of research evidence for policy guidance and a case study on how evidence can inform policy development in a Sub-Saharan country.

The findings of our main ESRC-DFiD funded studies were presented at global and regional conferences, posters and papers and our team was strategically placed to influence debates in policy and practice in institutions with leading roles in TB policy and practice. We used the data generated by our project's and other WHO-sponsored studies to engage in policy dialogue and data was incorporated into discussions of evidence for WHO Scientific Advisory Committees which resulted in new international policies (see for example http://www.who.int/tb/advisory_bodies/stag/en/index.html).

However, further studies to monitor if the new approaches improved access to diagnosis then highlighted the need to bring diagnosis closer to the patient. Over the last three years, we have therefore explored approaches to enhance TB case detection by addressing the barriers identified and provide an opportunity to bring services closer to poor and vulnerable groups. One of the packages was tested in the Southern Region of Ethiopia, where village-based Health Extension Workers (HEWs) facilitate access to diagnosis, reduce travel and the time taken to seek diagnosis and opportunity costs. The package is highly appreciated by the community and has doubled the number of cases diagnosed. The intervention is embedded in the local Health Service Extension Programme and has a highly equitable ethos that follows the principles of primary health care.

Currently, we envision that there is a strong potential to make changes in the national Ethiopian system to identify cases of TB and that similar changes may be implemented at a later stage in Nigeria. Despite all this progress and its high national and international recognition, changing a health system is a protracted process intersected with many other health, political and financial priorities and agendas. We therefore submit that changing the system requires a platform for the formal process of discussion by all stakeholders and a structured consideration of the integration of the package into the health system.

The process proposed will follow a participatory approach, engaging stakeholders at all feasible levels, providing factual information to enrich the discussion and organising formal discussions on issues critical for policy development. Although the process of developing guidelines at international level has become more structured and formalised in recent years, the same process is still fragmented and poorly documented in Sub-Saharan countries. We therefore propose to learn by doing and along the way document the process to facilitate the path for other interventions in the future.