Examining health system performance for indigenous people in the Peruvian Amazon through the lens of tuberculosis control.

This project will investigate and identify the key features required by the Peruvian health system to provide high-quality health services to vulnerable populations. In order to do this, we will focus on one particularly vulnerable group: Indigenous People from the Amazon who suffer disproportionately from several health problems including tuberculosis (TB). The Project will focus on the barriers, enablers and facilitators of deliverying context appropriate, feasible and culturally respectful services to detect, diagnose and treat TB among one particular indigenous group: the Ashaninkas from the Central Amazon of Peru, located in the región of Junin.

Ashaninkas are the largest Peruvian Amazonian IP group, and have a higher prevalence of TB compared with other urban areas in Peru. Most health care policies in Peru, including TB policies have been designed with an urban approach making such policies inappropriate and ineffective in rural areas such as the Amazon.

This Project aims to address the limitations of current health system delivery strategies in rural areas through the study of TB health policies and implementation practices in the Peruvian Amazon. Through interviews with different stakeholders such as indigenous TB patients, community leaders, representatives of indigenous organizations, regional and national health care officials we aim to identify the constraints in service delivery for vulnerable groups and the opportunity to make feasible changes. We will focus on cross-cutting systemic issues to provide high quality health care. Through a systematic analysis of the data collected and one workshop with each type of stakehodler we aim to develop using a participatory approach, a comprehensive package of scalable interventions in order to improve the quality of care delivered by the NTP to Peruvian Amazonian communities and other vulnerable groups.

This study has one primary research question fed by three secondary questions focused on indigenous groups
The primary question is: What are the key features that are required to strengthen the health system to improve the the detection, diagnosis, and treatment of tuberculosis for Peruvian Amazonian indigenous peoples (IP) and guarantee the provision of high-quality health services?
The secondary questions are:
(a) What are the barriers, enablers and/or facilitators for appropriate TB detection?;
(b) What are the barriers, enablers and/or facilitators for appropriate TB diagnosis? and
(c) What are the barriers, enablers and/or facilitators for appropriate TB treatment?

In each of these questions we will use the World Health Organization's building blocks approach to health systems (14) that looks into six major dimensions: leadership and governance, financing, health work force, information system, service delivery and medical products and technology.
We will capture views and information from three key scenarios:
i) community organizations, including indigenous federations;
ii) health facilities, including users and providers; and,
iii) health managers, and decision makers.

We will have three phases:
Phase 1 will address all three secondary questions;
Phase 2, will assemble all information gathered and, design/prepare a proposal of TB health system's strengthening; and,
Phase 3, will address a wider consultation with key stakeholders to validate the proposal.

The final product of this development grant will be a set of interventions to improve detection, diagnosis and treatment (DDT) of TB. These interventions are expected to be tested as part of the Research Grant stage in three health networks: Satipo (Junin), Maynas (Loreto) and Condorcanqui (Amazonas), all of them serving IP. The testing phase will entail implementation and evaluation of scalability, acceptability and economic feasibility. The evidence generated by this project will shape the development of a comprehensive package of scalable interventions aimed to improve the quality of care delivered by the NTP to Peruvian Amazonian communities.
The participatory design will develop research capacity and seed local involvement in decision making about healthcare priorities delivery.