Situation analysis rupandehi1

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  • 1. SITUATION ANALYSIS (DISTRICT LEVEL) TO IDENTIFY STAKEHOLDERS FOR TB-HIV COLLABORATION AND MAP SERVICE PROVIDERS (Year I) Report of Rupandehi District Government of Nepal THE BRITAIN NEPAL MEDICAL TRUST Ministry of Health and Population Serving the People of Nepal Since 1967 National Tuberculosis Centre Nepal 2010
  • 2. SITUATION ANALYSIS (DISTRICT LEVEL) TO IDENTIFY STAKEHOLDERS FOR TB/HIV COLLABORATION AND MAP SERVICE PROVIDERS Report of Rupandehi District Government of Nepal THE BRITAIN NEPAL MEDICAL TRUST Ministry of Health and Population National Tuberculosis Centre Serving the people of Nepal since 1967 Nepal 2010 2
  • 3. FOREWORD Since 1967 BNMT has been working with the government of Nepal to combat tuberculosis (TB). Initially, BNMT worked in Eastern Nepal to improve the health and well-being of the people living there and contributed in the development of National TB Programme (NTP). Since the beginning of the NTP, BNMT has been a partner of development and has been assisting the GoN within the framework of the National Tuberculosis Programme (NTP). The goal of the NTP is to reduce morbidity, mortality and transmission of TB until it is no longer a health problem. BNMT’s contribution to the National Tuberculosis Programme consists of quality assurance of TB sputum microscopy, expansion of treatment services, advocacy, communication and social mobilization, TB-HIV program and Public private mix within 27 districts of Nepal. NTP is receiving support from the Global Fund under Round 4 and Round 7 and BNMT is assisting NTC in the successful implementation of the activities proposed under both Rounds. Series of Operational Research (OR) activities to assist evidence based programme planning and implementation on TB-HIV were proposed by the NTP under Round 7 of the Global Fund support. One such intervention proposed is “Situation analysis to identify stakeholders for TB-HIV collaboration and map service providers”. Situation analysis studies are planned to assist in the programme planning and monitoring as it provides important baseline indicators against which the activities could be implemented and programme performance could be assessed. In light of the above, BNMT carried out a study “Situation analysis to identify stakeholders for TB-HIV collaboration and map service providers” in Rupandehi district in January 2010 at the time of implementing TB-HIV collaboration activities in the districts. The study aimed to assess the current situation of TB-HIV collaboration and mapping of implementation level partners in Rupandehi district. The ultimate objective of the study is to assist in better targeting of the TB-HIV collaboration programme in the respective districts and establish referral system between VCT and DOTS centers. 3
  • 4. BNMT wishes to take this opportunity to thank Dr. Kashikant Jha, NTC Director and other members of the PMU for their technical and financial support for the conduct of the study. I would also like to thank the Regional Health Directorate, Western Development Region, District Public Health Officer, HIV focal person, District Tuberculosis Leprosy Officer (DTLO), DACC coordinator and Chairperson of DOTS committee of Rupandehi district and all the other government line agencies and local NGOs for their support. My sincere thanks goes to the health service providers, female community health workers and community people at large without whose support and cooperation, this study would not have possible. Dr. Ghanshyam Bhatta, Program Coordinator, TB-HIV, BNMT led the BNMT team. I thank him for his leadership in the successful design and conduct of the study along with his team members. We at BNMT hope that the report will help to understand the current situation and strengthen the targeted planning and monitoring of the activities regarding TB-HIV collaboration to reduce the incidence of TB-HIV in the respective districts. Dr. Bhanu B. Niraula and Ms. Sadhana Shrestha Country Directors BNMT July 2010 4
  • 5. ACKNOWLEDGEMENTS I would like to express my sincere gratitude to all the participants who actively participated in the study and shared their experiences and helped in making the study a success. I would also like to thank Dr. Kashikant Jha, NTC Director, Regional Health Directorate, Western Development Region, District Public Health Officer, HIV focal person and District Tuberculosis Leprosy Officer of Rupandehi district for their technical and managerial support. The support from other local NGOs and the service providers working in all DOTS and VCT centers throughout the entire study was really appreciable which makes it possible to bring this study in this form. I am deeply indebted to Dr. Bhanu Niraula and Ms. Sadhana Shrestha, Country Directors, BNMT for their encouragement and support to carry out the study. My sincere appreciation goes to all the study team members including Mr. Sunil Acharya (Consultant), Ms. Manita Pandey and Mr. Suman Shrestha (Research Officers-field) and Ms. Sabina Rijal (Data Management Officer) for their hard work. Dr. Ghanshyam Bhatta Program coordinator, BNMT July 2010 5
  • 6. TABLE OF CONTENTS Page FOREWORD………………………………………………………………………....... ii-iii ACKNOWLEDGEMENTS……………………………………………………............. iv TABLE OF CONTENTS………………………………………………………………. v LIST OF TABLES AND FIGURES……………………………………………........... vi ABBREVIATIONS...………………………………………………………………….. vii-viii EXECUTIVE SUMMARY……………………………………………………………. ix-x Chapter 1: INTRODUCTION 1.1 Background................................................................................................................ 1-3 1.2 Brief profile of Rupandehi district ............................................................................ 3 1.3 Study Objectives........................................................................................................ 4 Chapter 2: METHODOLOGY ........................................................................................ 5-6 Chapter 3: KEY FINDINGS 3.1 TB and HIV cases……………...……………………………………………........... 7 3.2 TB and HIV service provision and practices………………………………………. 8-10 3.3 TB-HIV collaborative services………………..…………………………………… 10-12 3.4 Referral services……...…………………………………………………………….. 12-13 3.5 Coordination and reporting………………………………………………………… 13 3.6 Human resource available in the health institutions….............................................. 13 3.7 Training received by service providers……………………………………….......... 14 3.8 Findings of qualitative survey……………………………………………………… 15-22 3.9 Organization and management issue………………………………………………. 22-26 Chapter 4: CONCLUSION and RECOMMENDATIONS……...................................... 27-29 References ....................................................................................................................... 30 Annexes............................................................................................................................ 31-48 6
  • 7. LIST OF TABLES AND FIGURES Page Table 1 Estimated population and health service outlets in Rupandehi district……..... 3 Table 2 Reported TB and HIV cases, Rupandehi, 2010..……………………………. 7 Table 3 TB and HIV service providers………………………………….…….............. 8 Table 4 Community participation in DOTS programme, Rupandehi....………………. 9 Table 5 Services provided from VCT centers …………………………....................... 10 Table 6 Collaborative services provided from DOTS centers………………...…..…… 11 Table 7 Collaborative services provided from VCT centers ….……………………… 12 Table 8 Referral practices of DOTS and VCT centers……...….............……………... 12 Table 9 Distribution of health institution by reporting place ………………………… 13 Figure 1 Number of staffs employed in the health institutions..……………………….. 14 Figure 2 Training received by health institution staffs…………………………………. 14 7
  • 8. ABBREVIATIONS ART Antiretroviral Therapy ARV Antiretroviral CBO Community Based Organization DACC District Aids Coordination Committee DOTS Directly Observed Treatment Short-Course DPHO District Public Health Office EPI Expanded Programme on Immunization FCHV Female Community Health Volunteer FGD Focus Group Discussion GF Global Fund HFMC Health Facility Management Committee HIV/AIDS Human Immune Deficiency Virus/Acquired Immunodeficiency Syndrome HP Health Post INGO International Non-Government Organization MOHP Ministry of Health and Population NAP National AIDS Program NCASC National Centre for AIDS and STD Control NTP National Tuberculosis Program OPD Outpatient Department PHCC Primary Health Care Centre PLHIV People Living with HIV 8
  • 9. SAARC South Asian Association for Regional Cooperation SEAR South East Asia Region SHP Sub Health Post STAC SAARC Tuberculosis and HIV/AIDS Centre STI Sexually Transmitted Infections TB Tuberculosis VCT Voluntary Counseling and Testing WHO World Health Organization 9
  • 10. EXECUTIVE SUMMARY The objectives of the study were to: identify and map the existing service providers working in areas of TB and/or HIV, explore and document the current practices of TB-HIV collaborative activities, and explore the constraints and opportunities for developing TB-HIV collaborative activities among the service providing agencies in Rupandehi district. Methodology The study utilized a mix of quantitative and qualitative information. Quantitative information was obtained through secondary and primary sources. Secondary sources mainly included reports and documents published by NTC, NCASC and DoHS. Primary information was collected through the administration of semi-structure questionnaire among Key Informants. Qualitative information was collected through Focus Group Discussions among TB patients, HIV infected people and TB-HIV co-infected people in the community. Qualitative information related to TB and HIV issues at the district was collected through the interview of district level stakeholders and partners. A total of 15 DOTS centers and 4 VCT centers were visited for the study. Key findings A total of 2325 TB cases were reported in the hospitals and peripheral health service facilities of Rupandehi district in the period 2008/09. Majority of the male and female TB cases were between the age groups of 15-24 to 55-64 years. A total of 427 HIV cases were reported till the period June 2009. The highest proportion of infected cases was concentrated in age groups 25-44. The government had the largest TB and HIV service network in Rupandehi district. Only a few I/NGOs and 1 Medical college were involved in TB and HIV service provision in the district. Fifteen institutions were providing DOTS services and 4 institutions were providing VCT services. There was one ART center in the district being run by the government hospital. Only 1 health institution was conducting intensified TB case 10
  • 11. finding activities. The study results revealed that 12 institutions in Rupandehi district had community participation in their DOTS programme. All the DOTS centers were conducting collaborative activity like condom promotion and supply and about 90 percent were providing information on HIV to TB patients using IEC materials. The collaborative activities being conducted by VCT centers mainly focused on client education about TB and referral of HIV positive clients for clinical care. Very low numbers of institutions were providing referral services. Most patients were referred to I/NGO facilities or government hospitals. Overall, the practice of use of referral slips, documentation of referral cases and feedback mechanism was poor. The health institutions staffs were also lacking the skills in tackling the TB-HIV co-infection cases. Only the staffs of 75 percent VCT centers had got training on TB while the staffs of only 20 percent DOTS centers had got training on HIV. Almost all the health institutions also addressed the need of deployment of adequate and qualified human resources for the provision of services on TB-HIV co-infection. The study results indicated that the M&E mechanism in the government sector needs a lot of improvements. The study result indicated to numerous constraints and challenges being faced by the health institutions. The health institutions especially in the government sector were constantly facing interruptions in the supply of equipment and drugs and many of them were also lacking laboratory facility. The study findings showed that the governmental health intuitions i.e. PHC, HP and Hospitals did not have any services on TB and HIV co-infection. Many institutions had not followed the TB-HIV collaborative effort as it was supposed to. The coordination and collaboration mechanism among institutions was poor. Recommendations The findings of situation analysis therefore, points out to the need of strengthening of different aspects of TB-HIV program including skill development, institutional capacity building, referral mechanism, planning and M&E, and inter-agency collaboration in Rupandehi district 11
  • 12. Chapter 1: INTRODUCTION 1.1 Background Tuberculosis (TB) is considered as the leading infectious killer for people living with HIV/AIDS (PLHIV) worldwide with at least one in three people with HIV developing an active TB disease. HIV promotes the progression of latent or recent TB infection to active TB disease. TB-HIV co-infection has affected the African countries the most where 80% of global co-infected people reside. The rapidly growing epidemics of HIV seem to be a crucial barrier for TB control in South East Asia Region (SEAR) including Nepal. SEAR bears about 17% of Global TB and HIV co-infection cases. Thus, collaboration between TB and HIV/AIDS program is essential to improve access to comprehensive TB and HIV prevention, care and support services for affected populations and saving lives. Tuberculosis is one of Nepal's major public health problems. About 45% of the population is infected with TB, out of which 60% are in the productive age group. Every year, 44,000 people develop active TB, of whom 20,000 have infectious pulmonary disease. These 20,000 can spread the disease to others. Introduction of treatment by Directly Observed Treatment Short course (DOTS) has already reduced the numbers of deaths; however, 8,000-11,000 people continue to die every year from this disease. Expansion of the cost-effective and highly-successful DOTS treatment strategy has proven its efficacy in Nepal and has had a profound impact on mortality and morbidity. By achieving the global target of diagnosing 70% of new infectious cases and curing 85% of these patients, 60,000 deaths will be prevented over the next five years. High cure rates will reduce the transmission of TB, lead to a decline in the incidence of this disease, and ultimately aid in achieving our objectives of TB control. DOTS was introduced in 1996 after a joint Government/WHO review of the National Tuberculosis Programme (NTP) revealed that only 30% of TB cases were registered, and of these only 40% were treated successfully. The cure rate in the first cohort of DOTS patients was over 89%. By July 2000 the program had been expanded to 178 treatment centers in 66 districts and covered 75% of the population. The treatment success rate in DOTS centers is 12
  • 13. now approximately 89%; and, the national treatment success rate has reached nearly 85%. In the period 2007/08, a total of 33,419 TB patients were registered and treated under the NTP. One of the reasons for the persistent burden of TB is a failure to address the principal risk factors. The risk associated with TB can be put in three groups: the process of infection, progression to disease and outcome of a disease episode. Environmental factors that govern exposure to infecting bacilli include crowding, hospitalization, migration, imprisonment, ventilation and the ambient prevalence of infectious disease (mostly sputum smear positive). Among factors that influence the progression to diseases following infection, HIV co- infection is outstandingly important; others are age, sex, diabetes, tobacco, alcohol, TB strain virulence and malnutrition. Factors that affect the outcome of a disease episode include where treatment is given (eg. public or private sector), whether treatment is interrupted and drug resistance. The adverse outcomes most commonly measured are treatment failure and death. Some other risk factors for TB are commonly invoked but ill defined, ethnicity and poverty among them. In the context of Nepal, a situation analysis of TB-HIV co-infection was conducted in 2006. The study revealed the fact that there is an absence of policy framework for collaborative work as well as lack of resource allocation from government for collaborative activities. The study also highlighted lack of formal referral mechanism between two programs though some informal referral system exists in certain cases. However, both the program has major individual strategies like DOTS for NTP and VCT for HIV/AIDS. In recent times, Nepal has made some progress in TB-HIV collaborative program. The National Tuberculosis Program (NTP) in its revised Long Term Plan (2010-2015) has envisaged collaboration with National AIDS Program (NAP) to decrease the burden of TB-HIV in population affected by both diseases. In response to the dual burden of the diseases, a central level working groups (TB-HIV sub technical group) has been formulated recently. Similarly, task forces on TB-HIV coordination have been established and national policies and strategies are also formulated. Though these policies and strategies have been formulated, till date strong evidences are 13
  • 14. lacking as to the exact situation of the formulated collaborative activities at implementation level. In this context in January, 2010 BNMT carried out a situation analysis in Rupandehi district of Nepal. The purpose of the analysis was to identify and document the existing collaboration in formal and informal sectors and facilitate in identifying the gaps in TB/HIV collaboration both in policy and practice level. 1.2 Brief profile of Rupandehi district Rupandehi district, a part of Lumbini Zone, is one of the seventy-five districts of Nepal. The district, with Siddharthanagar as its headquarters, covers an area of 1,360 km². The population is currently estimated to be close to one million. Both government and private sector institutions are currently providing health services in the district. Government has the district wide health service network: 2 hospitals at the district headquarters and 5 Primary Health Care Centre (PHCC), 6 Health Post (HP) and 58 Sub- health Post (SHP) in the peripheral areas. It also has a district wide network of EPI and Outreach clinics and Female Community Health Volunteers (FCHVs) (Table 1). Table 1: Estimated population and health service outlets in Rupandehi district S. No Description Total number A Estimates of population sub-groups (for the period 2008/09) 1 District population 853259 2 < 1 year population 21640 3 < 5 year population 112542 4 Married women of reproductive age 163205 (MWRA) 5 Expected pregnancy 31240 B Government service outlets (for the period 2008/09) 1 Hospitals 2 2 PHCC 5 3 HP 6 4 SHP 58 14
  • 15. 5 EPI clinic 252 6 PHC/ORC clinic 222 7 FCHV 1290 Source: Department of Health Services (DoHS), 2009 1.3 Study objectives The overall objective of the study was to assess the current situation of TB-HIV collaboration and mapping of implementation level partners in Rupandehi district. The specific objectives were:  To identify and map the existing service providers working in areas of TB and/or HIV in Rupandehi district,  To explore and document the current practices of TB-HIV collaborative activities in Rupandehi district, and,  To explore the constraints and opportunities for developing TB-HIV collaborative activities among the service providing agencies operating in Rupandehi district. 15
  • 16. Chapter 2: METHODOLOGY The study utilized a mix of quantitative and qualitative information. Quantitative information was collected through review of institutional records and administration of semi-structured interview schedule (questionnaire) among health institution staffs working at district and peripheral or community levels. Qualitative information was collected mainly through Focus Group Discussions and in-depth interview. 2.1 Study population Following three categories of respondents were included in the situation analysis: The first category of respondents included the TB and HIV program focal persons, program coordinators, DTLA/O, other technical staff and in-charge of health facilities located at district and peripheral levels (e.g., government hospital and PHCC and HP, all DOTS centers and all VCT centers). Second category of respondents included TB patients, HIV infected people and TB-HIV co-infected people. Third category of respondents included officials of district level stakeholders and partner institutions including DHO, DACC and DOTS committee. A total of 15 DOTS centers and 4 VCT centers were visited for the study. 2.2 Data collection techniques and tools As mentioned above, both quantitative and qualitative technique was adopted to obtain the required information. Quantitative information was obtained through secondary and primary sources. Secondary sources mainly included reports and documents published by NTC, NCASC and DoHS. Primary information was collected through the administration of semi- 16
  • 17. structured questionnaire among Key Informants. A total of 19 Key Informants were interviewed in the district and peripheral areas. The interview schedule is presented in Annex 7 and list of institutions included in the study is presented in Annex 8 and 9. The information collected in the in-depth interview includes: - Estimated and reported cases of TB and HIV in the district, - Types of preventive and curative TB and HIV services provided by the health institutions including participation of the institutions in DOTS, - Practices of the health institutions on maintaining confidentiality of client information and referral of clients, - Affiliation of health institutions with various committees operating in the district and the institution’s participation in TB-HIV collaborative activities, - Information on management issues that included program planning, monitoring, reporting and supervision procedures, and, - Problem and constraints being faced by the institutions in implementing TB-HIV collaborative activities and suggestions on ways of strengthening the program. Qualitative information was collected through Focus Group Discussions among TB patients, HIV infected people and TB-HIV co-infected people in the community. Qualitative information related to TB and HIV issues at the district was collected through the interviews of district level stakeholders and partners. The in-depth interview guideline is presented in Annex 5 and 6. The information collected in the FGDs mainly focused on awareness of people on TB, HIV, DOTS and ARV; TB and HIV practices prevailing in the community; and problems faced by community people in seeking TB and HIV services. A total of 3 FGDs was organized in the community to solicit qualitative information. The FGD guideline is presented in Annexes 2, 3 and 4. 17
  • 18. Chapter 3: FINDINGS Information on various aspects of TB and HIV programs being conducted by various institutions in the district was collected. The information included details of program such as activities implemented, availability of DOTS, community participation in DOTS, provision of VCT services, availability of HIV testing and counseling facilities, case finding activities, and collaboration among institutions working in TB and HIV sector. This section presents general findings of the survey on these issues. 3.1 TB and HIV cases Table 2: Reported TB and HIV cases, Rupandehi, 2008/2009 Age group Male Female Total TB cases 0-14 3.3 7.6 5.5 15-24 21.1 23.0 22.0 25-34 19.8 24.1 22.0 35-44 13.0 16.2 14.6 45-54 14.0 10.5 12.2 55-64 16.6 11.5 14.0 65+ 12.2 7.2 9.7 (%) 100.0 100.0 100.0 Total N 1628 697 2325 HIV cases (cumulative figure) 0-14 7.7 6.6 7.1 15-24 2.3 9.6 6.0 25-34 40.6 42.8 41.7 35-44 36.8 32.5 34.7 45-54 10.3 7.2 8.8 55-64 2.3 1.2 1.8 65+ 0 0 0.0 (%) 100.0 100.0 100.0 Total N 261 166 427 A total of 2325 TB cases were reported in the hospitals and peripheral health institutions of Rupandehi district in the period 2008/09. There is no specific pattern of infection in male and 18
  • 19. female cases. By age, majority of the male and female TB cases were between the age groups of 15-24 to 55-64 years (Table 2). Similarly, a total of 427 HIV cases were reported in Rupandehi district till the period 2009. By age, the highest proportion of infected cases was concentrated in the age groups 25-44. The age pattern of HIV infection is similar to the infection pattern reported in NCASC data in that the infection is highest in ages between 15 to 44 years (NCASC, MoHP, 2010). 3.2 TB and HIV service provision and practices 3.2.1 TB and HIV service providers Various government, private Table 3: TB and HIV service providers, Rupandehi, sectors and I/NGOs are 2010 providing a variety of TB Program area S.N Sector/type Number 1 Government hospital 2 and/or HIV services in TB 2 Government peripheral 12 Rupandehi district. Among (DOTS center) health institutions 3 Medical college 1 these agencies, the HIV 1 VCT centers 4 government had the largest (VCT, ART 2 ART center 1 center) health service network: 70  Lumbini hospital runs both DOTS and ART center  Some of the sectors overlap with each other percent of the services were covered by government hospitals and peripheral health facilities like Primary Health Care Centre (PHCC) and health Posts (HP). The share of I/NGOs and private sector in TB and HIV service provision was 30 percent (Table 3). In case of government service outlets in Rupandehi district, hospitals are located in urban while PHC and HP are located in semi- urban or peripheral areas. The service outlets of I/NGOs and private sectors are mostly located in urban or semi-urban areas. Of the total institutions, 15 were providing DOTS services and 4 institutions were providing VCT services. The Lumbini hospital was providing both DOTS and ART services. 19
  • 20. On the question of maintaining confidentiality of patient information, all the health institutions (N=19) in Rupandehi district reported that they maintain confidentiality. 3.2.2 Community participation in DOTS programme At present, support groups of PLHIVs, CBOs and other community groups are encouraged to participate in TB-HIV collaborative activities with health institutions. These community groups could participate in identifying and referring suspected TB cases for TB services; identify and refer HIV vulnerable and at-risk population to HIV services; and, support and ensure DOTS for TB patients and ART-treatment adherence to AIDS cases. Thus at the time of this analysis 12 health institutions (80%) in Rupandehi district were reported to have community participation in their DOTS programme. All institutions were participating in DOTS through active DOTS committee. Similarly, two-third (66.7%) were also participating through community based or family based DOTS. Similarly about 40 percent were participating in DOTS through DOTS centers (Table 5). Table 4: Community participation in DOTS Community participation in DOTS Number Percent Yes 12 80.0 No 3 20.0 Total (N) 15 100.0 Methods of community participation Through active DOTs committee 12 100.0 Through community based DOTS or family based DOTS 8 66.7 Through DOTS 5 41.7 Total (N) 12 100 Note: Percent totals may exceed 100.0 due to multiple responses. 20
  • 21. 3.2.3 Services provided from VCT centers During the study period, all 4 Table 5: Services provided from VCT centers Rupandehi, 2010 VCT centers in Rupandehi Description Number of Percentage district were providing a range institutions Pre and post test counseling 4 100 of services to HIV infected HIV and STIs prevention 4 100 counseling patients. The services provided HIV testing 4 100 through all these institutions Condom promotion and supply 4 100 Referral services 4 100 include: pre and post test Quality assurance system for HIV 2 50 counseling, HIV and STI testing Quality assurance system for 2 50 prevention counseling, HIV counseling Note: Percent totals may exceed 100 due to multiple responses testing, condom promotion and distribution, quality assurance system for HIV testing, quality assurance system for counseling and referral services. 3.3 TB-HIV collaborative services The burden on TB services goes up due to the increase in TB attributable to HIV, coupled with the increase in HIV related morbidity and mortality in TB patients. Improved collaboration between TB and HIV programs leads to more effective control of TB among HIV infected. TB control can better contribute in HIV control which in turn leads to significant health gains. Thus the national TB-HIV collaborative policy focuses on the interface of TB and HIV/AIDS epidemic and joint programs are intended to be carried out as part of the health sector response to co-infection. In line with this policy TB-HIV coordination committees have been established at national, regional and district levels. At present, the district level Sub-committees are formed under the umbrella of District Aids Coordination Committee (DACC). The sub-committee is chaired by District (Public) Health 21
  • 22. Officer. They review performance and implement national policies and strategies of TB-HIV collaborative activities in the respective districts. The study results further revealed that most of the institutions with DOTS program were also conducting a variety of collaborative activities. All the DOTS centers were conducting condom promotion and supply activities. 26.6 percent DOTS centers were providing Syndromic STI treatment for TB patients and HIV prevention counseling. Similarly, nearly 90 percent of these institutions (N=13) were providing information on HIV to TB patients using IEC materials (Table 6). Table 6: Collaborative services provided through DOTS centers, Rupandehi, 2010 Total institutions Description Number Percent Condom promotion and supply 15 100.0 HIV prevention counseling 4 26.6 Provide syndromic STI treatment for TB patient 4 26.6 Providing information on HIV to TB patients using IEC materials 13 86.7 Total (N) (15) 100 Note: Percent totals may exceed 100.0 due to multiple responses. Regarding intensified TB case finding, only 1 out of the 15 institutions reported of conducting intensified TB case finding. During the study period, this activity was being conducted through home based care volunteers and through FCHV. In Rupandehi district, all 4 VCT centers were conducting some of the collaborative activities during the study period. The collaborative activities of all 4 institutions were mainly focused on client education about TB and STIs, referral of HIV infected clients for clinical care, screening of clients for STIs, and treatment for STIs. In addition, 3 institutions were also involved in other services like managing TB testing and TB treatment (Table 7). 22
  • 23. Table 7: Collaborative services provided through VCT centers, Rupandehi, 2010 Total institutions Description Number Percent Client education about TB 4 100.0 Client education about STIs 4 100.0 Referral of HIV infected clients for clinical care 4 100.0 Screening clients for STIs 4 100.0 Treatment for STIs 4 100.0 Manage TB testing 3 75.0 Manage TB treatment 3 75.0 Total (N) (4) 100 Note: Percent totals may exceed 100.0 due to multiple responses. However due to low awareness of government policy and guideline on coordination and collaboration, collaborative effort among these agencies had not been effective. In some cases especially in the government sector, the current collaboration is the result of personal effort of the institution staffs. This issue was pointed out by several stakeholders during the in-depth interviews. The interview results also indicated that most of the health institution staffs strongly felt the need for inter agency collaboration to tackle the issue of TB-HIV co- infection. They further pointed out the need for DACC and DOTS committee to be proactive in this regard. 3.4 Referral services Table 8: Distribution of health institutions by referral practices, Rupandehi, 2010 A total of 13 out of 15 or Total institutions Refer TB patient for HIV services about 87% DOTS centers in Number Percent Yes 13 86.7 Rupandehi district were No 2 13.3 providing referral services to Total (N) 15 100.0 Refer HIV patient for TB service TB patients for HIV Yes 4 100.0 services. Similarly, all 4 No 0 0.0 Total (N) 4 100.0 VCT centers also were also Use of referral slips found providing referral Yes 13 76.5 No 4 23.5 services to HIV infected for Total (N) 17 100.0 TB screening and treatment. The study results further showed that most of the patients were 23
  • 24. referred to government hospitals (Lumbini Zonal Hospital and Bhim Hospital). The patients were also referred to I/NGO institutions including Red cross, Navakiran, Astha and Namuna Bikash Parishad. Most of these centers practicing referrals (N=13) claimed that they always use referral slips while referring their clients to other institutions (Table 8). The study result also showed that relatively higher numbers of institutions that refer patients never or only sometimes communicate to the institutions where they referred patients to. In course of the study, only 4 institutions reported of always communicating about the referral patients. Likewise, all DOTS and VCT centers included in this study reported that other health institutions also send referral cases to them. Similarly, these centers claimed that they maintain records of incoming and outgoing referral cases. 3.5 Coordination and reporting Table 9: Distribution of health institutions by reporting The study finding indicated that place, Rupandehi, 2010 Total institutions Description majorities of DOTS and VCT Number Percent DOTS Center centers send their program DHO/DPHO 15 100.0 activities report to D/PHO and a Regional Health Directorate (RHD) 1 6.7 Total (15) 100 few other centers also send VCT Center report to the DHO/DPHO 2 50.0 NCASC 4 100.0 agencies/committees with whom Total (4) 100 they are affiliated to such as Note: Percent totals may exceed 100.0 due to multiple responses. NCASC (Table 9). 3.6 Human resource available in the health institutions The study findings showed that the number of staffs working in the health institutions ranged from less than 5 staffs (in 3 institutions) to more than 15 staffs (in 3 institutions). Slightly more than half (52.6%) institutions (N= 10) were employing 5 to 10 staffs. Similarly, another 3 of the institutions were employing 11 to 15 staffs (Figure 1). 24
  • 25. 3.7 Training received by service providers Regarding training on TB and HIV, the overall result showed that the staffs of all DOTS centers (N=15) had received training on TB while the staffs of only 20 percent DOTS centers (N=5) had received training on HIV. Similarly the staffs of all VCT centers (N=4) had received training on HIV while the staffs of three-quarter of VCT centers (75%; N=3) had received training on TB (Figure 2). 25
  • 26. 3.8 Findings of Qualitative Survey In the situation analysis, FGD was conducted among PLHIV, TB patient and TB-HIV infected persons in Rupandehi district. These discussions mainly focused on participants understanding of TB, HIV, and TB-HIV co-infection issues, health services seeking behavior, behavior of health service providers and type of services/support they receive from the service providing institutions. Similarly, in-depth interviews of health service providers including officials of district level committees and D/PHO were also conducted in the survey. The interview was broadly focused on the population sub groups that are at risk of TB and HIV in Rupandehi district, types of services available in health institutions, problems and challenges faced by the institutions in providing services and ways of resolving the problems and challenges. This section therefore presents general findings of the survey regarding these issues. 3.8.1 FGDs among PLHIV, TB patient, and TB-HIV co-infected Knowledge and understanding of TB, HIV, and TB-HIV co-infection All the PLHIV participants had knowledge about HIV. Majorities of PLHIV perceived HIV as a life threatening condition. Most had acquired detailed knowledge about HIV through different institutions they had visited after being infected by the virus. They had acquired the knowledge about HIV during the counseling sessions at the VCT centers. Only a few PLHIV possessed knowledge about TB. Majorities had no knowledge that HIV infected person is at high risk of getting TB. The FGD result indicated that very little or no information was given to them by the health service providers when they were diagnosed HIV positive. Only 3 out of 6 FGD participants were asked to get TB test by the service providers who diagnosed them being HIV positive. The TB-HIV co-infected participants had knowledge about HIV. They also had knowledge that once infected it cannot be cured. They however lacked other aspects of HIV infection such as modes of HIV transmission and ways of prevention. Like PLHIV, the co-infected 26
  • 27. participants had also heard about HIV from health service providers. A few of the participants had also heard about it from the radio. The co-infected participants had basic knowledge on TB. They had the knowledge that TB is a curable disease and knew about the symptoms such as cough and fever. The participants however were not aware about the proper dose or duration of drug intake for curing TB. The main source of their knowledge on TB was friends/neighbors in the community and the health service providers, both at VCT and DOTS center. The discussion with TB patient revealed that all the participants had good knowledge of TB including its symptoms, modes of transmission and ways of prevention. A few participants had heard about TB from the community people and on radio while most had heard about it from the health service providers. Regarding HIV, all had heard about the virus from different sources but did not know important information like modes of transmission and ways of prevention. The participants were not told about HIV by the health service providers. Overall, the discussion result with PLHIV, and TB patients indicated that PLHIV and TB- HIV co-infected participants had knowledge on TB and TB-HIV co-infection while most TB patients did not have much information on HIV and AIDS. The FGD result further indicated that TB patients were also not much keen on acquiring knowledge on HIV and/or TB-HIV co-infection. Health services seeking behavior The FGD results indicated that privacy in the health institutions is the main factor for determining the health services seeking behavior of PLHIV and TB-HIV co-infected people in Rupandehi district. The other factors that motivate people for seeking services are the behavior of health service providers and care takers, and extent of support they receive from the people who work in I/NGOs and within the HIV support network. Cost of services was also mentioned by the participants especially those with TB-HIV co- infected as the important factor in determining whether to seek services or not. In course of 27
  • 28. discussion, many of the participants mentioned that they could not go to private sector institutions due to the high cost of services even though the quality of care and support was good in those facilities. It was thus due to the cost factor that all co-infected participants had sought services from government institutions. In case of TB services, cost and service user’s trust in the quality of services and prospects of cure of the disease was found to be the reason for using the services. Accessibility of the services was also found to be one of the important reasons for them in using services. Overall, the participants were satisfied with the DOTS services provided from the hospital and other health institutions. The discussion results also revealed that all participants were given basic information about TB in the DOTS center that they had visited. The information they received was about the duration of drug use, need of sputum check up, preventive measures for TB infection such as harms of smoking and taking alcohol. All participants were also advised on the importance of regular intake of TB treatment medicine. These participants however were not informed about HIV or TB-HIV co-infection. Overall, all the TB patient had experienced good behavior from the service providers. Confidentiality of client information Of the 3 groups of participants (PLHIV, TB-HIV co-infected, and TB patient), PLHIV and the co-infected participants were more concerned about the practice of maintaining privacy about their visits at the health institutions that they had visited. According to them, privacy was one of the main factors that discourage them in seeking services in the health institutions. All the participants however expressed their satisfaction over the services of health service providers. They were also sure that information about their HIV positive status and other details were kept confidential at the health institutions where they had visited. 28
  • 29. Comparatively, the TB patient participants were more relaxed about the confidentiality issue. Nearly all the TB patient said they have not felt the need of maintaining privacy in the health institutions about their TB infection condition. Services/support provided by health institutions and I/NGOs About half of the PLHIV had undergone sputum test, and had received VCT and DOTS services. The PLHIVs were also getting some financial support for children education from various organizations. The PLHIV were also given drugs for HIV and TB. The participants also had received counseling in the health institutions that they had visited. The discussion result however showed that the information they received during counseling was limited. The participants were also referred for TB test and/or HIV test and were also given referral slips. 3.8.2 In-depth interviews with DOTS Focal Person, DPHO, VCT, ART and PMTCT focal persons Risk group for TB and HIV infection The in-depth interview results indicated that in Rupandehi district people mainly from marginalized communities, slum dwellers and poor and illiterate people are more at risk of TB infection. The interview results further indicated that the estimated cases of TB is around 1300 persons and incidence of TB especially in these communities is on the rise in recent years. In case of HIV, slum dwellers, factory workers, migrant workers and wives of migrant workers are believed to be more at risk of getting HIV. Apart from them sex workers, IDUs, MSM and people from poor and marginalized communities are also believed to be at risk of HIV. According to the respondents, HIV cases in Rupandehi district is increasing and currently estimated to be around 1000 persons. Majority of respondents also believed that the cases might be higher than what is estimated. 29
  • 30. Services at DOTS centers The main services available in DOTS centers in Rupandehi district are as follows:  Diagnosis and treatment of TB cases  Supply of drugs  Counseling on TB and,  Referral of complicated cases to other health institutions The interview results further indicated that out of 15 DOTS centers, 6 were also providing services to HIV infected. Most of the DOTS centers had focused their activities in awareness creation program as well. The responses of the DOTS focal persons further indicated that collaborative programs on TB and HIV have so far not been conducted through the centers and they are also not aware of any future plans of conducting such collaborative activities in the district. The interview results further indicated that there were no specific programs conducted from the centers to prevent TB patients from the risk of HIV infection. Likewise, no TB case finding among HIV patients was being conducted in the district. Services at VCT centers and other institutions for PLHIV and TB-HIV co-infected At the time of study, 4 VCT centers were providing services in Rupandehi district. Apart from the above, the other services available in selected government institution and I/NGOs in Rupandehi district for PLHIV and TB-HIV co-infected people are as follows:  Pre and post test counseling of clients  HIV testing  HIV and STIs prevention counseling  Quality assurance system for HIV testing  Quality assurance system for counseling  Condom promotion and distribution  Referral of complicated cases 30
  • 31. The interview results further indicated that so far no specific interventions were conducted from those centers to prevent HIV patients from the risk of contracting TB. It was however pointed out by the respondents that, information about the possibility of contracting TB was provided to the PLHIV during counseling and suspected cases were referred to DOTS centers for TB testing. In Rupandehi district one ART center was providing services. Apart from treatment this center provides counseling to patient about HIV related OI’s, recording and reporting and referral of HIV infected people to other health institutions as needed. Maintaining confidentiality of patient information The interview results indicated that the DOTS focal persons see no need of maintaining confidentiality of TB patients because according to them the community people including those who are infected have now accepted TB infection as curable disease condition. On the question of the system of maintaining confidentiality on information of HIV infected people, the respondents claimed that the information is kept confidential in the centre. In the interview it was also reported that the information is not disclosed to a third person or outsiders unless the clients want to disclose their information. All the respondents claimed that in order to keep the information confidential, first the client is assigned a unique code number and that number is given to the patient for cross reference. Then onwards the same code number is used in all prescription and other documents. Except counselor others do not know about the records of HIV infected persons. It was further mentioned that counseling session is conducted in a separate room. 3.8.3 In-depth interview with DPHO official The main role played by DPHO in the district is planning, organizing, implementing and monitoring/supervision of health programs. The DPHO also supports in activities such as TB 31
  • 32. and HIV case findings, provide counseling and treatment, organize training of health personnel and support IEC programs through its district wide network of health institutions. A number of institutions directly or indirectly are currently involved in TB and HIV programs. They provide a range of services including awareness creation, treatment, care and support for the infected persons. Inter-agency collaboration According to D/PHO there was no committee in Rupandehi district to oversee and coordinate TB-HIV collaborative programs. Likewise, there was also no in-built communication mechanism between the institutions to organize collaborative activities. It was however mentioned by the respondents that collaboration plan has already been initiated and they hoped that some mechanism for interagency collaboration will be in place in near future. The system of referring TB patient to VCT centre and vice versa was also being developed. According to the respondents so far advocacy on TB-HIV infection has been done and collaboration training for DOTS and VCT service provider was being provided. According to the DACC chair, recently HERD had formed public private mixed executive committee for planning and implementation of TB-HIV joint program. The committee had 13 members executive body chaired by executive director of Butwal Municipality, DPHO as secretary and DTLO, DACC coordinator. Representatives of various agencies such as Navakiran plus, and NATA, and volunteers, social workers and political parties were also the members of this committee. The committee had drafted general outline of work plan with major focus on strengthening existing VCT and DOTS center. Interventions to minimize the risk of TB-HIV co-infection ART and VCT services are the only intervention programs being implemented in the district in the HIV sector. In course of the interviews it was reported that there was no specific program or intervention aimed at preventing TB-HIV co-infection in the district. It was 32
  • 33. however mentioned that information about the possibility of TB infection is provided to the HIV infected people. The respondents in general perceive awareness creation on TB and HIV as one of the interventional programs for preventing TB-HIV co-infection in the district. National level support for TB-HIV activities In course of interview it was mentioned that national level support was being provided for selected types of TB-HIV collaborative activities. Those supports mainly focused on advocacy on TB-HIV co-infection and training to service providers. Community participation in TB and HIV programs In case of TB, community people were participating in TB programs through the DOTS committee in the institutions where those committees were functional. Community people co-operated in the committee’s activities and their involvement in TB program was good. Involvement of community people in HIV program however was virtually nonexistent in Rupandehi district. 3.9 Organization and management issues In course of situation analysis several issues related to organization and management of TB and HIV services was also raised among the stakeholders and health institution staffs through interviews and discussion meetings. The discussion mainly focused on four issues: planning, decision making, monitoring and supervision procedure and practices and constraints and challenges. 3.9.1 Planning procedures In case of government institutions the planning procedure for general health services shows an encouraging scenario. In course of the interviews nearly all PHCCs and HPs reported that after the identification of the health services need of the community, the annual and quarterly 33
  • 34. activity planning was done jointly by the health facility staff and the health facility management committees. Then the annual plan was presented in the district level meeting coordinated by the DPHO for approval. In case of government hospitals, the activity planning was done jointly by the hospital staff, DTLO and D/PHO. In I/NGOs and private sector institutions, it was reported that the planning was usually done at the central level. In most of these institutions, the district and peripheral staff propose the annual activities and the plan is finalized at the district and/or central level offices. Usually, no outside agencies were involved in the planning process. It was however pointed out by some respondents that occasionally, the activities were also planned by arranging meetings participated by stakeholder, partner agencies and coordination committees. In those meetings usually the health services needs of the district and communities were identified and prioritized. The government has implemented the Implementation Guidelines for TB and HIV/AIDS Collaboration for Planning of TB and HIV Programs in 2009. As directed in the guideline, NTP and NCASC have now initiated joint planning in order to ensure the implementation of collaborative TB-HIV activities within the district through DACC and DOTS committees. 3.9.2 Decision making procedures The interview result indicated that in case of peripheral government health facilities, most of the decision was made at the joint meeting of health institution staff and the management committees. In those facilities in case of major issues, the opinion of DPHO was also sought before making the decision. In case of VCT centers, DACC was also involved in the decision making process. Similarly in government hospital, the decision was usually made by the senior level staff or the institution head-Medical Superintendent. The interview result indicated that similar procedure was followed in I/NGOs private sector institutions in decision making. 34
  • 35. 3.9.3 Monitoring and supervision procedures Recently a core set of indicators and data collection tools have been developed within the national monitoring and evaluation (M&E) framework. Based on this, development of a joint supervision and monitoring system is now in progress. Once the system is finalized, monitoring and supervision will be done as stated by the guideline. At present, a review meeting is conducted every four months to monitor the program activities for TB programs. The study results indicated that the monitoring and supervision mechanism needs a lot of improvements for the monitoring and supervision of general health services. In the government sector, the peripheral health institutions such as HP and SHP are supposed to be regularly supervised and monitored by the D/PHO and/or Supervisor. It was also reported by some institutions that NTC was also involved in monitoring and supervision of TB programs. In practice, however, not much was being done to monitor and supervise the activities of these institutions. In course of situation analysis, very few institutions reported of regular monitoring of activities by their supervisors, DTLO or DPHO. In the absence of regular monitoring these institutions also do not get much input or feedback to sort out the problems or programmatic issues they encounter. The analysis findings showed that usually the institutions get only oral feedbacks. Similar situation was observed in case of I/NGOs and private sector institutions. These institutions also lack an established monitoring and supervision system. 3.9.4 Constraints and challenges The study result indicated that the health institutions were facing numerous constraints and challenges. Low awareness of community people about TB and HIV and TB-HIV co-infection issue was agreed as one of the main challenges faced by the health service providers both at district and peripheral levels. People with problems, especially those with HIV were stigmatized and discriminated in the community. 35
  • 36. The study findings showed that the governmental health intuitions i.e. PHC, HP and Hospitals did not have any or very limited services on TB and HIV co-infection. Since TB is one of the prioritized programs so far the focus of governmental sector is on TB alone. The health institutions including the hospitals do not have a holistic approach to address the issue of co-infection. Though the government has recently (2009) adopted a policy and guideline to address TB-HIV co-infection issue, the district level stakeholder/partner agencies and health institution staffs were not fully aware about this policy and guidelines. Thus the concerned institutions had not been able to set the future direction of TB and HIV program in the district. The other constraints and challenges indicated by most of the stakeholder/partner institutions and health facility staffs are summarized below: At the district level  Lack of adequate equipments and other resources - especially budget at D/PHO to work for TB-HIV co-infection  Lack of data base for the formulation and implementation of TB, HIV and TB-HIV co-infection activities in the district.  Lack of awareness among community people about TB and HIV or TB-HIV co- infection  Presence of stigma especially related to HIV.  Lack of training to health personnel on TB, HIV and TB-HIV co-infection  Lack of case finding activities on TB, HIV and TB-HIV co-infection.  Lack of community participation in TB and HIV programs.  Absence of local level plan and policy for the TB-HIV collaborative programs and monitoring of these programs  Several government agencies, I/NGOs and private sector institutions are working in TB and HIV sector in the district but the coordination and collaboration among these institutions is lacking  The TB and HIV programs are treated as separate issue and thus are currently implemented separately by different institutions. 36
  • 37.  For many institutions, maintaining privacy of clients has become a major challenge. This is especially true for some peripheral health institutions where there is no provision of a separate room or space for patient consultation/examination. At the institutional level  Due to the social stigma and attitude of community people towards HIV, PLHIV hesitate to visit VCT center for lab test and other services. Thus increasing the flow of VCT service seekers is one of the main challenges faced by VCT centers.  Lack of budget, test kits, training to service providers.  Changing the perspectives of community people towards HIV has become one of the challenges faced by the health institutions.  Health institution staff lack adequate skill in tackling TB-HIV co-infection cases  Most health institutions lack proper referral system that documents each of the incoming and outgoing referral cases. 37
  • 38. Chapter 4: CONCLUSION AND RECOMMENDATIONS Conclusion A total of 2325 TB cases were reported in the hospitals and peripheral health service facilities of Rupandehi district in the period 2008/09. Majority of the male and female TB cases were between the age groups of 15-24 to 55-64 years. A total of 427 HIV cases were reported till the period June 2009. The highest proportion of infected cases was concentrated in age groups 25-44. The government had the largest TB and HIV service network in Rupandehi district. Only a few I/NGOs and 1 Medical college were involved in TB and HIV service provision in the district. Fifteen institutions were providing DOTS services and 4 institutions were providing VCT services. ART service was also being provided by the government hospital. Only 1 health institution was conducting intensified TB case finding activities. The study results revealed that 12 institutions in Rupandehi district had community participation in their DOTS programme. Similarly, the VCT centers were conducting some of the TB-HIV collaborative activities at the time of the study. The collaborative activities mainly focused on client education about TB, referral of HIV infected clients for clinical care, managing TB testing and treatment. The major collaborative activities being conducted by the DOTS centers include condom promotion and supply and providing information on HIV to TB patients using IEC materials. Very low numbers of institutions were providing referral services. Most patients were referred to I/NGO facilities or government hospitals. Overall, the practice of use of referral slips, documentation of referral cases and feedback mechanism was poor. The health institutions staffs were also lacking the skills in tackling the TB-HIV co-infection cases. Only the staffs of 75 percent VCT centers had got training on TB while the staffs of only 20 percent DOTS centers had got training on HIV. Almost all the health institutions also addressed the need of deployment of adequate and qualified human resources for the provision of services on TB-HIV co-infection. 38
  • 39. The study results indicated that the M&E mechanism in the government sector needs a lot of improvements. In course of the study, very few institutions reported of regular monitoring of their activities by the supervisors or D/PHO. The study result indicated to numerous constraints and challenges. Low awareness of community people about TB and HIV and TB- HIV co-infection issue was agreed as one of the main challenges faced by the health service providers. The study findings showed that the governmental health intuitions i.e. PHC, HP and Hospitals currently did not have any services on TB and HIV co-infection. Many institutions had not followed the TB-HIV collaborative effort as it was supposed to. The coordination and collaboration mechanism among institutions was poor. The health institutions especially in the government sector were constantly facing interruptions in the supply of equipment and drugs and many of them also were lacking laboratory facility. For many institutions, maintaining privacy of clients had become a major issue. This is especially true for government peripheral health institutions where there was no provision for a separate room or space for patient consultation/examination. Recommendations Based on the findings of situation analysis following actions are recommended for effective implementation of TB-HIV collaboration activities in Rupandehi district: 1. The situation analysis showed that the health institution staff in Rupandehi district lack adequate skills in tackling TB-HIV co-infection. In course of the study, it was found that most of the providers were not clear on terminologies such as ‘Prophylaxis’ or ‘intensified TB case finding’. So there is a need for conducting orientation training to the health institution staff on these terminologies and standard procedures. 2. The health institution staffs, especially those working at DOTS and VCT centers were not clear on national TB-HIV policy and implementation guideline. These staffs need to have up to date information on these policies and guidelines. 39
  • 40. 3. The findings of in-depth interviews with health institution staff and the FGDs with PLHIV showed that the referral mechanism in the district health institutions was very poor. This finding calls for the need of a strong referral system in place with clearly spelled out referral procedures (use of referral slips, documentation etc) in the district for effective TB-HIV collaborative services. 4. Many stakeholders and health service providers felt that TB and HIV infected people were facing problems because of the long distance they need to travel from and to VCT/DOTS center. It is therefore recommended that the agencies should try to locate these centers in closer vicinity so that concerned people have easy access to both type of services. 5. Several government, private sector institutions and I/NGOs were working in TB and HIV sector in Rupandehi district but the coordination and collaboration among those institutions was lacking. Many stakeholders pointed out the need for establishment of a committee to conduct and monitor TB-HIV activities. Such committee should be able to establish good network between all I/NGOs and government offices involved in TB-HIV activities. 6. The discussion with PLHIV and health institution staff revealed that HIV infected people are highly stigmatized and discriminated in the community. This finding showed the need for conducting awareness creation activities in the community. 7. Many government institutions were lacking a separate counseling room for HIV infected people. This not only discourages people to visit these facilities but also has proved difficult for the service providers in maintaining privacy of the patient who visit them. Thus it is recommended that establishment of a counseling room be regarded as a priority issue in these institutions. 8. Adequate data base on TB and HIV needs to be created for the formulation and implementation of TB, HIV and TB-HIV co-infection activities in the district. The findings of situation analysis therefore, points out to the need of strengthening of different aspects of TB-HIV program including skill development, institutional capacity building, referral mechanism, planning and M&E, and inter-agency collaboration in Rupandehi district. 40
  • 41. REFERENCES WHO, Manual for Participants Management of TB/HIV Collaborative Activities, 2005 TB-HIV Co-infection; action, Advocacy to control TB Internationally [Online]. 2008 [Cited February 9, 2009]; Available from: URL:http://www.action.org/site/geteducated/134 SAARC Tuberculosis Centre ‘Situation Analysis of TB, HIV/AIDS and TB/HIV co-infection in the SAARC region’- SAARC/ Canada Regional tuberculosis and HIV/AIDS project ; December 2003 Communicable Diseases: Tuberculosis; Fact sheets on TB [Online]. 2006 April [Cited 2009]; Available from: URL: http://www.searo.who.int/EN/Section10/Section2097/Section2106_10679.htm Health Research and Social Development Forum (HERD), Situation Analysis of TB and HIV Programme Collaboration in Nepal; November 2006, Final draft submitted to World Health Organization (WHO), Nepal. Ministry of Health and Population, National Centre for AIDS and STD Control (NCASC) and National Tuberculosis Centre (NTC) ' Policy and Strategy Guideline on Collaborative TB/HIV Control Activities in Nepal' [Draft copy]. Department of Health Services (DoHS), MoHP, Annual Report 2064/65 (2007/2008), Nepal Government, 2009 41
  • 42. ANNEXES Annex 1 The Britain Nepal Medical Trust (BNMT) Situation Analysis (District Level) to Identify Stakeholders for TB/HIV Collaboration and Map Service Providers Consent form Namaste! My name is………………………. I have come from an organization named ' The Britain Nepal Medical Trust'. Currently this organization is conducting one research called situational analysis of TB/HIV collaboration at implementation level. The general objective of this study is to assess the existing situation and recommend possible interventions for implementing TB/HIV collaborative activities in Morang/ Banke / Kanchanpur district of Nepal. I request you to participate in this study. You will not be directly benefited by participating in this study but we hope that the information given by you will be very useful in future while implementing TB/HIV collaboration activities. Your participation in this interview will be completely voluntary and you could halt this interview at any time if you wish. However, I want you to participate as your views will be important for us. I would like to assure you that the information provided by you will be totally kept confidential. The total time for this interview will be about 45 minutes to 1 hour. If you are interested to participate in this interview, I would like to request you for the agreement to participate here. If participant disagrees ………… 1. Stop here If participant aggress …………… 2. Start the interview Name of participant: ………………… Date: ……………… Signature………………. I would like to thank you very much for your participation and would like to welcome in this interview. 42
  • 43. ANNEX 2 Focus Group Discussion (FGD) guideline for TB patients 1. Health Seeking Behavior: - Types of service providers consulted till now from the beginning (which service provide collaborate and which don’t) - Reason behind selecting that type of health care provider (Probe for: accessibility, affordability, confident in getting cured) - Responses from each service provider (Probe for: Service provider’s behavior) - Information kept confidential or not? -Consequences from particular service provider (Probe for: Diagnosis, counseling, referral etc.) 2. Knowledge and perception of the disease: (from where did you get this information?) 3. Information provided on HIV/AIDS from service providers: - Mode of transmission - Symptoms and causes -Displayed relevant materials (IEC materials) - Treatment (ARV services) 4. Referral to VCT from any of the service providers consulted? - Used referral slip - Well documented about referral in the organization 5. Services used - HIV testing -Used VCT services - HIV prevention counseling, Condom promotion and supply - Syndromic STIs treatment - Trainings provided on HIV - Other types of service provided 43
  • 44. ANNEX 3 Focus Group Discussion (FGD) guideline for PLHIV (People living with HIV) 1. Health Seeking Behavior: - Types of service providers consulted till now from the beginning (which service provide collaborate and which don’t) - Reason behind selecting that type of health care provider (Probe for: accessibility, affordability, confident in getting cured) - Responses from each service provider (Probe for: Service provider’s behavior) - Information kept confidential or not? - Consequences from particular service provider (Probe for: Diagnosis, counseling, referral etc.) 2. Knowledge and perception of the disease: (from where did you get this information?) 3. Information provided on TB from service providers: - Mode of transmission - Symptoms, cause and diagnosis methods - Treatment duration and facilities (DOTS center) - Types -Displayed relevant materials (NTP/ IEC materials) 4. Referral for TB investigation from any of the service providers consulted? - Used referral slip - Well documented about referral in the organization 5. Services used? - Have ever been tested sputum? - Trainings provided on TB - Other types of facilities received (i.e. Nutritional services) 44
  • 45. ANNEX 4 Focus Group Discussion (FGD) guideline for TB/HIV co-infected people 1. Health seeking behavior - Types of service providers consulted till now from the beginning (which service provide collaborate and which don’t) - Reason behind selecting that type of health care provider (Probe for: accessibility, affordability, confident in getting cured) - Responses from each service provider (Probe for: Service provider’s behavior) - Information kept confidential or not? - Consequences from particular service provider (Probe for: Diagnosis, counseling, referral etc.) 2. Knowledge and perception of the disease (from where did you get this information?) 3. Information provided on TB/HIV - Mode of transmission - Symptoms, cause and diagnosis - Treatment method (treatment duration and facilities) - Displayed relevant materials (IEC materials) 4. Referral for TB/HIV investigation from any of the service providers consulted? - Used referral slip - Well documented about referral in the organization 5. Services used? - HIV testing/sputum testing - Use of VCT/DOTS services - HIV prevention, counseling, condom promotion and supply - Training provided on TB - Other types of facilities received (i.e. Nutritional services) 45
  • 46. ANNEX 5 In-depth Interview guideline for services provider at VCT and DOTS centre Information on interviewee Date of interview: Name of interviewee Age (years) Post: Sex: Name of health institution: Working experience in current institution: Working experiences in related field (years) 1. General Information: 1.1 How are you being involved in TB and/or HIV program? (Roles and responsibilities) 1.2 Can you tell in brief about the situation of TB and HIV/AIDS of the region? (Probe: for high risk groups, estimated number of cases, marginalized group) 2. Service related questions: 2.1 Are you providing services in TB or/and HIV or/and TB-HIV co infection from your organization? 2.2 If yes, what sort of services are you providing? (probe: Types of services, training, counseling, treatment and care etc) 2.3 If no, is there any plan in future to provide such services? (probe: related to TB-HIV co- infection) 2.4 What are the major interventional aspects conducted at your organization to decrease the burden of TB in PLHA? (Probe: prevention of TB, case finding, linkage with DOTS, TB control) 2.5 What are the major interventional aspects conducted at your organization to decrease the burden of HIV in TB patients? (probe: Provision of HIV testing and counseling, 46
  • 47. introduction of HIV prevention and treatment method, HIV/AIDS care and support, ART treatment) 2.6 What is the prophylaxis for TB at your Institute? 2.7 What sort of OI prophylaxis is done for HIV patients in your institute? 2.8 How do you assure the confidentiality of clients is maintained? 2.9 What are the existing resources that you utilize for TB or/and HIV or/and TB-HIV co- infection in the organization? 3. Problems and challenges 3.1 What are the major problems and challenges that you face while providing the services on TB or/and HIV or/ and TB-HIV co-infection? How these problems can be overcome? (Probe: problems from patients, resource distribution, social stigma, role of health worker, superstition) Thank You 47
  • 48. ANNEX 6 In-depth interview guideline for stakeholders (DTLA, DAAC Chairperson, HIV focal person, DOTS committee) Name of interviewee Age (years) Post: Sex: Name of health institution: Working experience in current institution: Working experiences in related field (years) 1. General information 1.1 How are you being involved in the TB and/or HIV program? (Roles and responsibilities) 1.2 Can you tell in brief about the situation of TB and HIV/AIDS of the district? (Probe for high risk groups, estimated number of cases, marginalized group) 1.3 Who are the major stake holders in providing services on TB and HIV/AIDS in this district? And, what services are they providing? (Probe for following services : TB care, VCT, PLHA support, clinical HIV/AIDS care, STI treatment, Family planning, Condom promotion, Nutritional support, Orphan care/ social support, Psychological support) 2. Mechanism for collaboration 2.1 Is there any existing coordination committee for TB/ HIV joint activities in this district? 2.2 If yes, who are the members and how is it functioning? 2.3 If no, is there any plan to form one in the future? 2.4 Has any surveillance of HIV prevalence among TB patient been conducted in this district? 2.5 If yes, when and by who? What was the major finding? (Get a copy of report if available) 2.6 Has any collaborative plan for TB/HIV joint activities been done in this district? 2.7 If yes, can you describe it in brief (Probe for: when was planning done, who participate, what (were the major activities, what was the source of resources) (Get a copy if available) 2.8 If no, is there any plan in the future to do make such collaborative planning? 2.9 What sort of researches has been conducted in this district in the field of TB and/or HIV/AIDS? (Probe for: any periodic survey, periodic surveillance, time of the research, 48
  • 49. researching organization/ individual, study site, major objective of the research, method, major findings) 3. Intervention to decrease burden of TB in PLHA and burden of HIV in TB patients 3.1 What are the major interventional programs conducted in the district to decrease the burden of TB in people living with HIV/AIDS (Prevention of TB, TB case finding, linkages with DOTS, Tuberculosis control in health care settings) 3.2 What are the major interventional programs conducted in the district to decrease the burden of HIV in Tuberculosis patients (Probe: Provision of HIV testing and counseling, introduction of HIV prevention and treatment methods, HIV/AIDS care and support, 3.3 Are there any focused program for marginalized groups and high risk group? If yes, can you tell it in brief. How do you ensure the confidentiality of the clients is maintained? 3.2 How do you ensure the confidentiality of the clients is maintained? 3.3 What are the existing resources for TB and HIV joint activities in the district. (Human resources, drugs, equipment, donors and others) 4. Support from National level 4.1 What sort of support are you getting from national level for TB/HIV joint activities. (Probe: from national TB/HIV coordination committee, Types of training provided, motivations and others) 4.2 Does any monitoring and evaluation activities being done by national level? 4.3 Is there any communication system prevalent (Probe: within service providers of TB and HIV, within clients of TB and HIV services) If yes, can you tell it in brief. (Get any document if available) 5. Community participation 5.1 In your opinion, how are community people involved in the TB and HIV programs (Probe for TB, HIV and TB/HIV joint collaboration) 6. Problems/Challenges and Action to be taken 6.1 What do you think are the major problems and challenges in the implementation joint TB/HIV collaboration activities in this district? How these problems can be overcome? (Probe: Problems in mechanism of coordination, resource distribution, from community, social stigma, role of health workers) 49
  • 50. ANNEX 7 The Britain Nepal Medical Trust (BNMT) Situation Analysis (District Level) to Identify Stakeholders for TB/HIV Collaboration and Map Service Providers Questionnaire for Health Institution Name of Interviewer: Time of start: Date of interview: …./…./…….. Time of end: Section I General Information 1 Health institution no : ………… 2 Name of health institution: …………………………………. 3 Address: District: ……………….. Ward no……….. Tole Name………………………………… 4 Name of interviewee: …………………………………………………………………… 5 Position: ………………………………… 6 Duration of work in the organization : ………………. Years SN Questions Answers Code Go to 7 What type of organization is this? I/NGO  1 Peripheral government HI (PHC, HP, SHP)  2 Government Hospital  3 Private organization  4 Urban DOTS center  5 Medical College  6 8 What is the catchment area of this Health Institution (Define in terms of geographical location. (Get a map if available) 9 What is the distance from catchments area to this health institution? 50
  • 51. 10 Which ethnic groups live in the catchments area? 11 What is the number of Total target population ? Total population What is the number of estimated TB cases in this Estimated TB cases 12. area? What is the number of estimated HIV cases in this Estimated HIV cases 13 area? 14 Is the information on client kept confidential in the Yes  1 institution? No  0 15 If not, why? 16 Please provide us the following information on the clients (Registered in the Health institution) Age group TB PLHA Male Female Other sex Female Male Female Other sex 0-14 15-24 25-34 35-44 45-54 55-64 65+ Section II : Type of service provided and status of collaboration in TB/HIV program SN Questions Answers Code Go to 17 Does this institution provides service on Tuberculosis (DOTS)? 1 13 Yes  0 17 No  18 Does this centre provide any of the following collaborative Yes. 1 activity? (Multiple answer possible ) Discuss HIV with TB patients as part of routine patient IEC  No. 0 Provide VCT to TB patients  HIV prevention counseling  Condom promotion and supply  51
  • 52. Provide clinical care for PLHA with TB  Provice syndromic STI treatment for TB patients  Referral of non TB patients with HIV  19 Is this institution is conducting intensified TB case finding? No  Yes. 1 (Multiple answer possible) No. 0 Yes, through private practitioner  Yes, through VCT centres  Y es, through PLHA groups  Yes, in prisions  Yes, through Home based care volunteers  Yes, traditional healer  20 How is community participated in DOTS? (Multiple answer Yes. 1 possible) No  No. 0 Yes, an active DOTS committee is there  Yes, through Community based DOTS or Family based DOTS  Yes, through Home based care volunteers  Others( Specify)  21 Does it provide any of the following services? (Multiple answer Yes. 1 possible) Contrimoxazole preventive therapy for TB patients  No. 0 Clinical care for patients with HIV and TB  ART for eligible patients for HIV and TB  22 Does this institution provides service on VCT? Yes  1 18 No  0 20 23 What types of services are provided through this center? Pre and post test counseling  Yes. 1 (Multiple answer possible) HIV and STIs prevention counseling  No. 0 HIV testing  Condom promotion and distribution  Post test club or referral for ongoing support  Quality Assurance system for HIV testing  52
  • 53. Quality Assurance system for counseling  24 Does this institution provides any of the following collaborative activities?(Multiple answer possible) Client education about TB  Yes. 1  Client education about STIs  No. 0  Referral of HIV (+) clients for clinical care  Screening clients for TB  Treatment for TB  Screening clients for STIs  Treatment for STIs  25 Does this institution provides services on Treatment of HIV? Yes  1 21 No  0 23 26 What types of services are provided through this centre? Yes. 1 (Multiple answer possible) Nursing care  No. 0 HIV prevention counseling  Condom promotion and distribution  Treatment of HIV-related clinical problems  ARV referral/ treatment  Syndromic STIs treatment  Universal HIV prevention precautions  Referral to appropraite supportive services  27 Does this institution provides any of the following collaborative Cotrimoxazole preventive treatment  Yes. 1 activities? (Multiple answer possible) No. 0 Isoniazid preventive treatment  Antiretroviral treatment (ART)  28 Do you refer TB patients for HIV services? Yes  1 No  0 29 Do you refer HIV infected people for TB services? Yes  1 No  0 30 Where do you refer normally? 31 Do you use referral slip while referring patients? Yes  1 No  1 32 How often do you communicate with the center? Never  53
  • 54. Sometimes when we refer patients  Always when we refer patients  Conduct regular meetings  33 Do any referral patients come to your organization from other Yes  1 28 organization? No  0 31 34 Do you provide feedback of the referral patients to the organization from where they had been referred? Yes  1 No  0 35 How do you provide these feedbacks?  In written document 0 During meetings held with other organizations  1 From supervisors  2  3 From the patients who had been referred 36 Do you maintain the documentation of referral patients coming Yes  1 from other organization at your organization and vice versa? No  0 37 Is this organization affiliated with any coordination committee? Yes  1 No  0 38 If yes, which coordination committee is this organization affiliated with? 39 In which aspects you are getting support from the committee? Planning of joint TB /HIV activities  0 Mobilization of resources for program  1 Capacity building including training  2 Section III : Management of the cases 40 How planning of the activities is done at your organization(Probe: Types of planning activities, involved organization, personals, planning process) 41 Details of service providers in the organization Position Filled Training (TB)- Specify Training (VCT)- specify Doctor Nurse HA 54
  • 55. ANM AHW Others (Specify) Others (Specify) 42 How decision making is done in this organization (Probe: Involved personal, decision making method, example of decision making ) 43 Where do you report the activities of your organization? Only within this organization  0 DHO/DPHO  1 Regional health office  2 NTC  3 NCASC  4 NTC and NCASC  5 Others (Specify)  6 44 How supervision and monitoring is done in this organization ?(Probe: Who supervises, when subject, feedback, oral or written) 45 Specific Budget Type Budget Equipment Period of Remarks Support GoN NGO INGO Others (Specify)……… 46 In your view what might be the challenges in this organization for TB/HIV collaboration ?(Probe: Care and treatment, budget management, equipment, transmission management ) 47 Any other things that you like to suggest for the proper collaboration of TB/HIV 55
  • 56. ANNEX 8 Health institutions working in the area of TB in Banke district S.N. Organization Address 1. Lumbini PHCC Lankapur, 2 2. Lumbini Zonal Hospital Butwal, 7 3. Anandaban Health Post Anandaban, 9, Salghari 4. Chhapiya Health Post Dayanagar, 3, Chhapiya 5. Semara Bazaar Health Post Makrahat, 8 6. Parauha Health Post Parauha, 1 7. Devdaha Sub-Health Post Devdaha, 1, Khaireni 8. Dhakdhai PHCC Dhakdhai, 4 9. Bhim hospital Siddhartha, 13 10. Universal college of medical science Siddhartha, 1, Ranigaun 11. Basantapur PHCC Basantapur, 9 12. Raypur PHCC Raypur, Aamua 13. Motipur PHCC Sau, Pharsatikar, 1 14. Majhgauwa Health Post Beninagar, 9 15. Karmachhawa Health Post Bishnupur, 4 56
  • 57. ANNEX 9 Health institutions working in the area of HIV and AIDS in Banke district S.N. Organization Address 1. Namuna Integrated Development Council- Butwal, 10, Milan path VCT 2. Mono Supporting Mapple Group (BDS)- Siddhartha, 8, Bank Kaloni VCT 3. Nagarjun Development Community (NDC)- Butwal, 11, Milanchowk VCT 4. FPAN-VCT Butwal, 7, Hatbazar 5. Lumbini Zonal Hospital, ART Butwal, 7, Hospital line 57
  • 58. ANNEX 10 58
  • 59. Study Team Members Dr. Ghanshyam Bhatta Programme Coordinator Mr. Sunil Acharya Report Writing (Consultant) Ms. Manita Pandey Research officer Mr. Suman Shrestha Research officer Ms. Sabina Rijal Data Management Officer Ms Rinju K.C. Consultant 59
  • 60. 60