The Solucion TB Program in Mexico_Jessica Chen


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The Solucion TB Program in Mexico_Jessica Chen

  1. 1. The SOLUCION TBProgram in MexicoStrategies and learning from a systems-strengthening program to improveTuberculosis control in Mexico2004-2012CORE Group Spring MeetingTB and HIV/AIDS Working Group SessionApril 240, 2013
  2. 2. The SOLUCION TB Programexperience• SOLUCION TB was a collaborative TB prevention andcontrol program carried out by PCI from 2004-2012.• Funded by USAID (Over $8 Million)• Phased implementation approach (phases 1-4):– Phase 1 –dedicated program in Baja California (Tijuanaand Mexicali), funded via the CSHGP– Phase 2 –expansion phase, reaching 13 states(including Baja) and 35 municipalities– Phase 3 –piloting of a comorbidities program addressingTB-HIV/AIDS and TB-Diabetes. Reduced funding andscope– Phase 4 –continuation of the comorbidities program• Results include strengthening of public health system inMexico with improved TB control outcomes
  3. 3. Basic info on TB and needs inMexico• 2012: Over 19,700 cases (allforms), 80.7% pulmonary• 50% with an associated disease(comorbidity)• 18.5% Diabetes and 5.6%HIV/AIDS• 10.8% in 19 yr and younger• Incidence: 16.9 (with someregions as high as 48)
  4. 4. Basic info on TB and needs inMexico• The country has strong norms and lab systems, andcontinuous supply of medication and testing materials.• Varied levels of leadership, management capacity andtraining of staff. Stigma and discrimination are present.• Health center staff delivering services for 20+ priorityprograms• Insufficient awareness about TB basic symptoms andhigh levels of misinformation and myths.
  5. 5. SOLUCION TB: Phase 1 (CS)• 100% TB Child Survival Grant• Work in Tijuana and Mexicali municipalities toimprove TB treatment success• increased number of dedicated TB staff,improved training and communityengagement trough community healthworkers• Despite change in national level leadership,cultivated a strong working partnership withUSAID and the NTP• Results: improved treatment success ratesand decreased treatment default; improvedcollaboration between MOH and affectedcommunities• Due to good results, a request for expansionreceived
  6. 6. SOLUCION TB ExpansionStrategies (Phase 2)• Systems strengthening and Capacity Building at National,State and Local levels (Information systems, management)• Advocacy, Communication and Social Mobilization (ACSM)• Recruitment, training and deployment of TB workers• Regional and inter-departmental collaboration
  7. 7. SOLUCION TB Expansion –keychallenges• Lack of awareness aboutACSM• ‘Silo’ design with little or nocollaboration with relateddepartments (Lab, healthpromotion, socialcommunication, etc.)• Lack of experience workingwith communities (and viceversa)• Highly medicalized model,with pre-conceived attitudesabout persons with thedisease
  8. 8. SOLUCION TB Expansion ModelRecruitment, training and deployment ofdedicated TB staff (DOTS workers mainly)Advocacy, Communicationand Social MobilizationCapacities for: health personnel,PTB and affected communitiesMOHStrengthenningDOTS workersACSMPATB
  9. 9. SOLUCION TB ExpansionlocationsCd. JuárezChihuahuaCreelTorreónSaltilloMonclova MonterreyGuadalupeHidalgoSta. CatarinaReynosaMatamorosTampicoVeracruzPoza RicaCoatzacoalcosTuxtlaTapachulaComitánCosta, Istmo, TuxtepecAcapulcoLázaro CárdenasApatzinganMoreliaZapopanTlaquepaqueGuadalajaraZacatecasOjocalienteFresnilloTijuanaSanta AnaCaborca
  10. 10. Advocacy, Communication andSocial Mobilization (ACSM)• Participatory planning -assessing strengths and areas ofimprovement through I-STAR(nationally and in the 13states/35 jurisdictions)• ACSM training to build MOHcapacity in ACSM strategies• Moving beyond theory – lack ofinformation on “how to”• ACSM planning included purposeand measuring objectives• Innovations:– Empowering DOTS– Internal and external ACSM– Greater Participation of PeopleAffected– Changed language (frompatient to person affected) toinfluence attitudes/behaviors– Utilization of Voices andImages (Photovoice) andtestimonials
  11. 11. Expansion: Main Results andproducts• Achieved 91.2% treatment cure rate(85% MOH target) and 0.8% treatmentdefault, for target participants in the35 jurisdictions• 3.8 million reached through 3,000ACSM activities and events (including56,971 community members directlyparticipating)• 48% staff absorption by MOH (from127 TB workers hired/deployed)• First Knowledge, Attitudes andPractices, and first TB Stigma studiesin the country• Mexico’s work highlighted in the STOPTB first ACSM promising practicespublication• Improved data (cohort) analysis anddecision-making
  12. 12. Expansion: Main Results andProducts• Facilitated inclusion of ACSM strategies into TB preventionand control strategies (new position at NTP and 2 states),ACSM plans• Increased visibility of stigma and discrimination and raisedimportance of mitigation strategies– 8 Voices and Images galleries produced and touringexhibits– Nuestra Casa exhibits: 7 exhibits (UTEP, Cancun, Oaxaca,Reynosa, Tijuana, Atlanta and UTEP)– Educational pieces on rights and responsibilities, andmyths and realities (brochure and video)– Luchando Por Una Voz power points (photo journals ofpeople with TB)
  13. 13. Voices and Images and NuestraCasa“Loneliness in TB”Alejandro, 19“Is your heart like this?”Alma, mother to MarianitaNuestra Casa Exhibit
  14. 14. SOLUCION TB Expansion –keylessons learned• Integration of strategies that ‘humanize’ the disease werekey to transforming disease-based to person-centered care-changed language influencing attitudes-identification and mitigation of stigma, listening to thoseaffected• Internal ACSM took place before working with externalaudiences– empowering of TB staff• Invested where needs in service-delivery were greater:– health centers and jurisdictions (municipalities)• Change supported through improved communication andcoordination (face-to-face regional meetings twice per year;‘organic’ mentoring/support; monthly online newsletters)
  15. 15. Phase 3 –piloting ofcomorbidities model Jan-Sep2010Proposal based on cohort analysis in previousphases which identified clear challenges in TB-HIV/AIDS and TB-Diabetes *• Coordination between 3 programs: Diabetes,HIV/AIDS and NTP at the national level– How? Started at national level, usedcompelling, convincing evidence• Initial national training for 7 states (includingone jurisdiction)• Comorbidity plans established to improvecomorbidity testing, diagnosis and referrals• Clear identification of challenges to integrationof detection and referrals• Phase 4 model designed
  16. 16. Phase 4: TB and comorbidities• Based on results of phase 3, detection targets established• Expanded training to jurisdiction level and throughout• Data base developed by NTP and PCI to facilitatedocumentation and improve reporting• New awareness and educational pieces developed tointegrate messaging• Monthly follow-up and bi-annual regional workshopsRaising the profile and credibility of the TB program was bothan outcome and a strategy for fostering greatercollaboration with the other 2 programs.
  17. 17. SOLUCION TB comorbiditiesmodel: joint planning andimplementationAwareness, testing and referrals of TB (andDiabetes). IPT.Awareness, Testing andreferrals; DM casemanagement for TB-DM.Awareness, testing andreferrals. Supports DM casemanagement targets.SSATBHIV/AIDSDiabetesPATB, VIHy DM
  18. 18. Phase 4 Main Results: Clinical– Prevalence of HIV/AIDS-TB co-infectionincreased 154% between 2007 and 2011(8.5% previous 4 year period). TB-DMprevalence increased 73%– Testing of HIV in TB increased 71%,testing for DM in TB increased 73%– 96% of people with HIV received info onTB– Screened 25,089* persons with TB,HIV/AIDS or Diabetes (~790/month)– 68% of individuals with TB document HIVtest– 4,582* MOH staff (physicians, nurses, labtechnicians and health promotionworkers) trained in co-morbidities– Mexico a pioneer in TB-Diabetes work inthe Americas
  19. 19. Phase 4 Main Results: Systems• Comorbidities information system needsidentified (to be ‘incorporated’ into new data-base when available)• Testing for HIV in TB and for TB in HIVelevated to ‘indicators of excellence’ .• Comorbidities positions created at nationallevel (and replicated in two states) to includeHIV/AIDS and Diabetes• First joint co-morbidity monitoring pilot-testedby HIV/AIDS, TB and Diabetes programs• National and state training platforms nowinclude comorbidities learning• HIV/AIDS-TB and Diabetes-TB expertsresulted in: a) key recommendations widelydistributed, b) modification of ARV guide, andc) revision of new TB national Norm
  20. 20. Challenges and Lessons Learned• In spite of independent design and operation, integration of referralservices at referral is possible and necessary• Modified information systems to make comorbidities work visible andmeasurably contribute to sustaining results– At all levels: from identification of indicators to formats to be used atthe health clinic level.• Ongoing, quality training is necessary, and should be supported throughfollow-up on-site visits– Quality training includes peer sharing and learning (cross training),connecting planning with training, utilizing a needs-based and stateof the art information sharing approach, and combination withhands-on application and follow-up• Successes built upon previous phases (including person-centeredapproach, and ‘humanization’ of TB care strategies)– Mutual respect, local ownership, etc.– TB Program took leadership (joint decisions about who ‘owns’documentation, supplies, etc.• Utilization of IPT was more challenging than expected. Additionalanalysis needed to determine how much recommendations from expertsummits contribute to improve it
  21. 21. Key challenges that remainTB-HIV/AIDS• Inconsistent clinicalguidelines for use of IPT• Lack of collaboration with(and fear of) communitiesand NGOsTB-Diabetes• Burden of DM (volume ofpeople with DM• Those who might need it* themost are not accessing healthservices• Consistency of expansion/dissemination ofcomorbidity model• Inclusion of comorbidity indicators into new healthinformation system (TBD)
  22. 22. The way forward• MOH is committed tosustaining results– MOH requiring states tocontinue/adopt the models;national training; ongoingsharing of tools; etc.• Collaboration betweenHIV/AIDS, Diabetes andTuberculosis programs to beexpanded nationally• New information system to bedeveloped by MOH toincorporate key indicators• PCI to disseminate andreplicate systems-strengthening/integrationmodel in other countries
  23. 23. Testimonials• “PCI represented abreakthrough forTuberculosis (TB)control inMéxico. A person-centeredapproach to servicedelivery, improvedawareness of the disease,and improved co-morbidityservices for TB-HIV/AIDSand TB-diabetes are directresults of this partnership.”• Dr. Martín Castellanos Joya,Director, National TuberculosisProgram, Ministry of Health,México• “We are really pleased with theachievements of this programwhich has focused oncoordination and collaborationamong the institutions thathandle HIV/AIDS, TB, anddiabetes. The program hasimproved services provided topatients; systems of strategicinformation; and diagnosis andtreatment. We are satisfied thatthe program has exceeded itsgoals. I hope that Mexicoconsiders the success of thistruly Mexican program as animportant complement to allthe efforts in the countryfighting against TB.”• Sean Jones, Deputy Director,USAID México
  24. 24. Thank You!• More information? please contact:• Blanca Lomeli•• Or Jessica Chen•• 858 279 9690••