Making it happen - Increasing access to diagnosis and treatment for tuberculosis
Lead Research Organisation:
Liverpool School of Tropical Medicine
Department Name: Child and Reproductive Health
Abstract
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.
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.
Planned Impact
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.
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.
People |
ORCID iD |
Luis Cuevas (Principal Investigator) |
Publications
Anderson De Cuevas RM
(2014)
Barriers to completing TB diagnosis in Yemen: services should respond to patients' needs.
in PloS one
Datiko DG
(2015)
Exploring providers' perspectives of a community based TB approach in Southern Ethiopia: implication for community based approaches.
in BMC health services research
De Cuevas RM
(2016)
Patients direct costs to undergo TB diagnosis.
in Infectious diseases of poverty
Obasanya J
(2015)
Tuberculosis case detection in Nigeria, the unfinished agenda.
in Tropical medicine & international health : TM & IH
Tulloch O
(2015)
Patient and community experiences of tuberculosis diagnosis and care within a community-based intervention in Ethiopia: a qualitative study.
in BMC public health
Description | This grant aimed to engage health and financial policy decision makers at different levels (district, region, national and international level to integrate a new approach to diagnose and treat tuberculosis at the community level. We learnt that to influence policy it was necessary to engage policy makers and program managers very early on, to create opportunities to share experiences at national and international level and to engage with international donors to jointly sensitize local policy makers to the findings of the study. The process of engaging policy makers is difficult and relies on approaches ranging from publicizing scientific findings, translating these findings to accessible language, engaging policy makers and promoting advocacy to the national program by external funders. |
Exploitation Route | The National TB Control program requested the Global Fund to Fight AIDS, TB and Malaria (GFATM) to allocate $10 million for the identification, diagnosis and treatment of individuals with TB at the village level. The GFATM agree to this request. The project demonstrates that early advocacy and multilateral engagement with stakeholders facilitates mainstreaming research finding into disease control programs. A similar and successful approach was implemented in Nigeria and thus the GFATM funded these new implementation approaches in Ethiopia and Nigeria. Since 2017, the GFATM allocated $100 million for countries to increase case detection for TB, mostly through the implementation of active case finding, similar to the studies described here. |
Sectors | Communities and Social Services/Policy Healthcare |
URL | https://www.youtube.com/watch?v=lWetOVUA89o |
Description | Our findings contributed to the increasing body of evidence that extending the reach of health services through formal/informal health workers increases the detection of TB. This approach has been accepted by most national TB control programs and has become a supplementary activity to routine health services for TB. This acceptance and frequent implementation is a major change to some 10 years earlier, when national programs were reluctant to conduct these activities. Furthermore, the Global Fund to Fight AIDS, Tuberculosis and Malaria, earmarked $100 million in the last funding round to promote these activities in high TB burden countries |
First Year Of Impact | 2017 |
Sector | Healthcare |
Impact Types | Policy & public services |
Description | 6. The Ethiopian Government adopted the TB REACH approaches. |
Geographic Reach | Africa |
Policy Influence Type | Citation in other policy documents |
Impact | Selected quote: Global Fund Portfolio for the Government of Ethiopia. The project TB REACH described in page 38. Strategic objective 2 - Improve community ownership on prevention & control of TB, TB/HIV, MDR TB and Leprosy. - The request to include an allocation for the health Extension Workers activities described in page 58 and page 63. Selected quote: In order to fill the remaining gap in case detection, CCM requests additional funding from the above allocation amount, to be used for implementation of innovative high impact CTBC interventions (based on the results of successful TB REACH CTBC models) focusing on intensified case finding among pastoralists communities and other 4 major regions with high TB burden. |
URL | http://www.theglobalfund.org/en/portfolio/country/?loc=ETH |
Description | Ethiopian Government request the GFATM to allocate funds to expand the approach to a larger number of communities: TB care and prevention. |
Geographic Reach | Africa |
Policy Influence Type | Citation in other policy documents |
Impact | Selected quote: Implementation of innovative community TB cares interventions: Additional 8.4million is requested for three years to detect and treat 32,352 additional TB cases. In Ethiopia HEWs of the HEP in the community currently identify and refer presumptive cases to diagnostic units. The country target is for the HEWs to increase the referral of presumptive TB cases to more than 50% of cases attending diagnostic centres. In the new approaches, HEWs will be more actively involved in the diagnosis and treatment of the cases in the community. This activity will be additional to the conventional DOT centre activities and will serve as a backbone to increase the number of cases detected. It is expected that engaging HEWs in community-based TB prevention and control efforts would increase their contribution to smear-positive case notification rate of 65%43. The community HEWs will provide services for 65% of smear positive cases notified. This would mainly contribute to increasing case finding and reverse the declining trend in TB case detection. The TB REACH project implemented in southern Ethiopia had a high impact on TB case finding by addressing the main barriers to seeking diagnosis and making the services accessible to the community. In this application, the country targeted increasing case finding through strengthening the existing health system and implementing high impact intervention such as the interventions illustrated by the TB REACH project in phased manner. The country therefore, plans to scale up the TB REACH CTBC intervention packages in four major regions (SNNPR, Oromia, Amhara and Tigray) of the country. These regions are of predominantly rural population, high burden of TB and a declining case finding. Additional funding is required to implement the community-based approach and enhance case finding in these high burden areas. The interventions will require; strengthening the health centre-health post links; improve the community awareness of TB and of the service and the implementation of the interventions by actively engaging HEWs and the health development army. This would require budget additional budget amount $8.4 million with community-based approaches and selected interventions will be implemented in a phased manner. In the first phase of the grant, NTP will continue to sustain and expand the interventions already implemented in the Southern Region of Ethiopia (to better characterize and document the TB epidemic in the whole Region), learn from the interventions and monitor its impact) and scale up the interventions to at least 10 zones. In the second phase, and based on the lesson learned during the initial implementation of the interventions, the approach will be further scaled up in the regions selected, to include 25 new zones and to consider expanding to the remaining regions of the country. The key interventions include strengthening the basic packages implemented by the NTP. Under this concept note period, the CCM-E request $8.4million request for implementation of the above innovative community TB case interventions of which $1.62million used for familiarization and training of HCWs $1.62 million, $1.49 million for implementation cost (district level program review, air time for Key ACSM activities),$2 procurement of Non - medical items (Motorbikes, reagents, fuel and maintenance), $3.3 million for procurement of medical items like cartridges, ILED microscopes, experts). With this approach over all additional 32,352 TB cases will be detected and put on treatment. |
URL | http://www.theglobalfund.org/en/portfolio/country/?loc=ETH |
Description | Leaflet from the Stop TB Partnership highlights the project achievements |
Geographic Reach | Africa |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | Brief quote: "The project has not only brought the three million people living in Sidama Zone within the healthcare system but has also turned TB into a disease that can be talked about out loud. People suffering from TB no longer have to suffer stigma as well. Moreover, they have learned that the disease can be treated and cured without the patient having to leave home." |
URL | http://www.stoptb.org/global/awards/tbreach/interactive/pdfs/ethio-liv.pdf |
Description | MPs from Canada Visit Hawassa TB REACH project. |
Geographic Reach | Multiple continents/international |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | The link describes the link to the MPs report, which highlights the link to the Ethiopian TB REACH project. TB REACH seeks "to promote early and increased case detection of TB cases and ensure their timely treatment, while maintaining high cure rates within the national TB programmes." TB REACH has proven itself as a life-saving, cost-effective solution to the global TB crisis: Reaching the missing 3 million. TB REACH funds projects that focus specifically on finding and diagnosing cases of tuberculosis in the most vulnerable, hardest to reach regions of the world. Community-driven results. Grants from TB REACH are much smaller compared to the Global Fund-the maximum funding amount per project is $1 million-which encourages community-led initiatives to apply. These small projects can then be scaled up, and some are even adopted by their respective country's Ministry of Health for further expansion. Using unique, innovative approaches, many of the programs funded through TB REACH are utilising new technologies and methods of case detection to ensure they are reaching as many people and diagnosing as many cases as possible. |
URL | http://www.results-resultats.ca/en/action-info/tb-using-innovation-end-global-epidemic/ |
Description | UK parliamentarians visit Ethiopia-LSTM TB REACH Project in Awassa, Ethiopia. |
Geographic Reach | Africa |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | UK members of parliament visited the TB REACH Project twice 2013/2014. UK MPs then highlighted the programme in the World UNION Lung Health Conference in Barcelona in 2014. A quote from the link "Funded by the WHO's Stop TB Partnership, the objective of the TB REACH project is to promote early and increased case detection of tuberculosis (TB) cases and ensure their timely treatment, while maintaining high cure rates within TB programmes at national level." |
URL | http://www.lstmed.ac.uk/news-events/news/uk-parliamentarians-visit-ethiopia-lstm-tb-reach-project-in... |
Description | Contribution to Global Fund application |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | Yes |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Under consideration After his input, the National Programme asked the proposal writing to include the activities in the case for support. |
Year(s) Of Engagement Activity | 2014 |
Description | Dr Datiko, Ethiopian Director of TB REACH was invited to contribute to the Ethiopian concept note for the GFATM application |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Dr Datiko, Ethiopian Director of TB REACH was invited to contribute to the Ethiopian concept note for the GFATM application; to describe the main components to be proposed and identify priority areas for community based diagnosis and treatment of TB. The text related by the TB REACH activities was written by Dr Datiko with technical support from Professor Cuevas. The text was incorporated into the Ethiopian Government Concept note for the Global Fund allocation request. |
Year(s) Of Engagement Activity | 2014,2015 |
Description | Executive Director of The Global Fund to Fight AIDS, Tuberculosis and Malaria highlights REACH Ethiopia, as an example of innovative interventions |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | Yes |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Talk estimulated the debate on how to reach poor populations without access to diagnosis and raised the profile of the community based package (Barcelona 2014). A similar debate was presented to the 2015 UNION conference in South Africa. After the talk there were many inquires to elaborate on the details of the package. |
Year(s) Of Engagement Activity | 2014,2015 |
URL | http://barcelona.worldlunghealth.org/programme/daily-programme/friday-31-october-2014#plenary-sessio... |
Description | National conference for policy makers, politicians, National Ministry of health staff and Tuberculosis control programme managers |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | In August 2016, we conducted a national conference for policy makers, politicians, National Ministry of health staff and Tuberculosis control programme managers at State, District and Woreda level in Ethiopia, with attendance of more than 150 delegates to discuss the implementation of the TB REACH activities funded by the Global Fund to fight AIDS, Tb and Malaria. |
Year(s) Of Engagement Activity | 2016 |
Description | RESULTS UK leads delegation to Ethiopia by UK Parlamentarians |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | Yes |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Parliamentarians were very impressed with our work and promised to highlight it as an example of innovative interventions. This was followed by UK parliamentarians attending the TB Conference in Barcelona 2014, highlighting examples of good practise to reach communities, including our TB REACH project. Dr Datiko and Dr Theobals were invited to the Golbal Health Assembly in New York to presented the project, as an example of activities that increase the reach of services for women. |
Year(s) Of Engagement Activity | 2014 |
URL | http://blog.results.org.uk/2013/03/01/results-uk-leads-delegation-to-ethiopia/ |
Description | TB REACH Ethiopia hosted the National TB Research Annual Conference |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | TB REACH Ethiopia hosted the National TB Research Annual Conference, which was attended by the State Minister for Health Dr Kebede Worku. Dr Worku then visited villages supported by the TB REACH project to familiarise himself for with the project. |
Year(s) Of Engagement Activity | 2015 |
URL | https://www.usaid.gov/ethiopia/speeches/9th-national-tb-research-annual-conference-and-commemoration... |
Description | Women and girls at the heart of the post MDG agenda: TB REACH Ethiopia presented at United Nations General Assembly |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | Yes |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | The profile of the package was highlighted as an example of innovations to reach women and children in remote and poor communities Increase profile at the international level and influence of polies |
Year(s) Of Engagement Activity | 2013,2014 |
URL | http://www.lstmed.ac.uk/about-lstm/news-and-media/latest-news/2013/july-dec/women-and-girls-at-the-h... |