Tuberculosis and PSI


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Tuberculosis and PSI

Jennie Quick, PSI

TB Working Group Showcase

CORE Group Spring Meeting, April 29, 2010

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  • [This is a slide to allow you to walk through what the presentation will cover.]
  • [The photos are from: Love Test: Swaziland (HIV Counseling and Testing Campaign) Women Holding Hands: Sex worker program in India Condom Distribution: Pharmacy in Laos]
  • [This slide should be a simple overview of PSI’s work in TB. The key points are:] PSI provides TB services in Africa and Asia (more than 7 countries – but I would emphasize the continents instead of the number of countries.), including TB/HIV work in several countries Services include: DOTS (treatment) in Myanmar and Pakistan (soon in India too) Laboratory diagnosis Screening Treatment support Contact tracing Communications to encourage treatment seeking behavior and discourage discrimination (have done or will do comms in India, Laos, Myanmar, Kenya, Romania, and--in partnership with Project Hope--Central Asia).
  • [The conference organizers were particularly interested in a discussion of the public/private mix (PPM) social francishing model we use in Myanmar and Pakistan, so this is something to spend a bit of time on.] Social franchise – An adaptation of a commercial franchise in which the developer of a successfully tested social concept (franchisor) enables others (franchisees) to replicate the model using the tested system and brand name to achieve a social benefit . The franchisee, in return, is obligated to comply with quality standards, report sales and service statistics, and, in some cases, pay franchise fees. All service delivery points are typically identified by a recognizable brand name or logo. PSI uses this model not just for TB, but also for RH and CT Options for social franchising include Full, partial, PPM, hybrid, accreditation only. PSI uses the Public/Private Mix (PPM) model : WHO definition: PPM is the involvement of all health care providers - public and private as well as formal and informal - in the provision of TB care. WHO states that PPM is needed when there is high utilization of the private sector and non-NTP public sector such as medical colleges, army, etc. but services are not high quality . According to a Center for Global Development Nov. 2009 report, more than one-half of all health care (including care to the poorest people) is provided by the private sector (private doctors, other health workers, drug sellers, etc). The goal of employing a PPM is to expand access to TB screening, diagnosis and treatment by building the number of providers that are accessible to the target population (i.e. minimizing distance to the provider, ensuring providers are non-stigmatizing care, etc.). One of the main barriers to access to TB care is distance - i.e. public sector sites are too far away to access regularly. So by working with private sector providers that are located closer to people's homes, we expand access. Stigma is regularly faced by individuals accessing public sector sites and working with private providers so closely gives us an opportunity to provide intense stigma reduction messages - ideally preventing some of the stigma that others experience in the public sector. We provide DOTS in Myanmar and Pakistan through a public/private mix social franchise model. In both of these countries, we have integrated TB screening and treatment into private social franchises in collaboration with the government ministries of health.
  • [This slide is a brief overview of our Myanmar program.] -Myanmar is our oldest TB program, launched in 2004 . It employs a passive case-finding model (this a more “traditional” TB model). GPs in the Sun Quality Health franchise are trained to screen for TB if patients present with key symptoms;. Individuals who are identified as TB suspects are referred to a lab (private or public) for diagnosis ; PSI trains lab workers to diagnose. Treatment is provided by the Sun Quality Health provider. Treatment is free of charge. Drugs are provided by the government. QA monitors visit project sites regularly to ensure high-quality service provision. PSI-Myanmar also trains CHWs who work with SQH providers to offer treatment adherence support, conduct contact tracing and follow-up on defaulters. “Contact tracing” is working with the individual who has TB to identify anyone they've been in contact with and who they may have given TB to (I.E. what family members do they sleep near, have they been spending time with specific friends, etc.). Contact tracing is actually considered a type of active case-finding. Tracing clients who default is actually tracking down clients who have stopped taking treatment to try and get them back on. Demand Creation
  • [If you are asked about these numbers, refer the questioner to Megan or Petra.] 150 of 326 townships in Myanmar 691 providers, 145 labs in franchise Almost 117,000 tested and 54,000 registered as having TB, including almost 8,000 with active pulmonary TB Category 1 = active pulmonary TB cases WHO treatment success rate goal is 85%, so 84% is close Case detection rate goal is 70% 4% default rate is low We are reaching the poor CHWs follow up on cases that have been identified
  • [This slide is to provide basic background on our Pakistan program.] Greenstar was our second social franchise TB provider – launched in 2005 Employs an active case-finding model which means that community health workers actively seek out potential TB suspects.This is largely done through door-to-door screenings and screening in so-call “hot spots” (for example, places where street-based people or IDUs gather), to identify potential TB suspects. (Only done in areas with high TB burden or this is not cost-effective). Suspects are referred to sputum collection events in the community, which occur 1-2 times/month/community. Sputum is collected here and individuals are notified by a CHW if they are positive for TB (health care worker follow-up at their home with diagnosis). (M ost countries have not yet implemented same-day spot-spot testing. Petra has asked Megan for a realistic turn-around time; technically it could be one day because it doesn't take long to prep the slides, but she’s not sure in practice what the time frame is). If they have TB, they are referred to a GreenStar provider. If an individual is not identified through the community events, and instead is screened by a GreenStar provider during a regular visit (similar to Myanmar), the individual is referred to a qualified lab for diagnosis. Pakistan works with the RNTCP (the national TB control program) to train both providers of DOTS and also qualified lab technicians. The government also provides drugs free of charge. Again, CHWs provide adherence support, contact tracing, etc.
  • [Again, if you are asked about these numbers, refer the questioner to Megan or Petra. ] Over 1,000 providers & 49 labs Over 36,000 trtmt supporters trained 2.1 million people reached Over 40,000 registered TB cases 89% trtmt success rate (vs. 85% goal of WHO) 33-51% contribution to case detection rate 21,862 ss+ (54%)
  • [Red ad is from India; ad with girl is from Kenya] Pakistan and Myanmar are our only treatment programs – we are working to expand this highly successful model. In addition to treatment , we also provide a host of other TB services and…. communications ! PSI has strength in health communications and we have worked to apply this expertise to TB. Throughout the last six years , we’ve executed TB campaigns in the countries listed.. Not ALL of the countries currently have active TB communication campaigns. The campaigns focus on increasing awareness about TB, building treatment seeking behavior, encouraging TB treatment adherence and decreasing stigma around TB. We also design and execute campaigns about the interaction of TB and HIV.
  • [This slide is to introducing our TB/HIV activities. We are not doing as much as we should in TB/HIV (although I wouldn’t say this publicly…) but we’re working to expand it!] -We provide TB screening as part of HIV counseling & testing (HCT) services in all of the countries listed on this slide. This includes both PSI CT locations and public centers with provider-initiated CT. [ I would not state that TB screening during HCT is part of our standard operating procedure (I mentioned this when we met) because it then begs the question “Why are not all CT programs doing it?” This calls into question the quality of our services and opens a can of worms. So this slide can be kept short and simple.] The screening tool has been designed to be extremely user-friendly and has been adapted where necessary. Individuals identified as TB suspects through the screening are referred to laboratories for diagnosis. PSI works to track all referrals. We achieve a 30-60% referral tracking rate , depending on the country, and varying over time. Example is Zimbabwe around 50-60% depending on month. A “tracked referral” means a client is referred (for trtmt or diagnosis), and PSI follows up w/facility confirm client reported for diagnosis/trtmnt. [If asked about our referral tracking rate, identify that the main challenge is turnover of health system staff (who have to record referrals). For more detailed information, they should contact us. (I wouldn’t get caught up in a conversation about referrals.)]
  • [This slide is self explanatory. We presented a poster on this at the Lung Health Conference in 2009 in Cancun. This is also featured in an article on TB/HIV integration in the April issue of Impact.] 2006 launch The South African National Department of Health requires that all TB patients be tested for HIV , but in 2006, only a third were being tested. The activities have occurred at 2 hospitals . They involved mobile HCT for out-patients and TB patients . From 2006-2009, over 7,000 patients tested for HIV. Overall rate of patients testing positive was 37%; 90% of TB patients tested positive for HIV. 80% of referrals accessed follow-up care. Telephone tracking
  • [The Zimbabwe program is launching some new activities. This discusses one of them.] We have conducted TB screening in our Zimbabwe HCT sites for many years . The model was as described above – we referred suspects to public sector diagnosis and tracked referrals. To further improve the level of care provided by our HCT centers, Zimbabwe has introduced sputum microscopy onsite in five clinics. There is a plan for expansion to all 18 sites in the coming year. This development means that an individual, after being identified as a TB suspect, is referred to sputum collection IN the clinic . Removing the need for a referral that may or may not be used. Individuals who are diagnosed with TB are referred for treatment to a public sector facility.
  • [This slide is simply to outline where we see PSI and TB going in coming years.] Coming years: Scale-up existing, launch new (3 clicks) Comms (1) Expand TB svcs at HCT (2) Support provider-initiated HCT for TB suspects, patients
  • Tuberculosis and PSI

    1. 1. Tuberculosis and PSI Jennie Quick, PSI April 29, 2010
    2. 2. Overview <ul><li>Who is PSI? </li></ul><ul><li>PSI’s approach to public health </li></ul><ul><li>What is social franchising? </li></ul><ul><li>PSI and TB </li></ul><ul><li>Next steps </li></ul>
    3. 3. Who is PSI? <ul><li>International non-profit </li></ul><ul><li>Incorporated in 1970 </li></ul><ul><li>More than 60 country offices </li></ul><ul><li>Based in Washington </li></ul><ul><li>World leader in social marketing and behavior change communication </li></ul>
    4. 4. Key Health Areas <ul><li>HIV/STI prevention </li></ul><ul><li>HIV Counseling and Testing (CT) </li></ul><ul><li>Reproductive Health </li></ul><ul><li>Malaria </li></ul><ul><li>Diarrheal Disease </li></ul><ul><li>Pneumonia </li></ul><ul><li>Tuberculosis </li></ul>
    5. 5. PSI and TB
    6. 6. What is social franchising? <ul><li>Franchise Responsibility: </li></ul><ul><li>Training </li></ul><ul><li>Quality Assurance </li></ul><ul><li>Monitoring and Evaluation </li></ul><ul><li>Drugs, Supplies and Consumables (as appropriate) </li></ul><ul><li>Communication, Branding and Demand Creation </li></ul><ul><li>Franchisee Responsibility: </li></ul><ul><li>Quality Service Provision (according to standards and protocols) </li></ul><ul><li>Implement Recommendations </li></ul><ul><li>Recording and Reporting </li></ul><ul><li>Participate in Network Activities </li></ul>Once established, a successful social franchise can be rapidly scaled-up with limited cost and expanded to include other health services.
    7. 7. Sun Quality Health - Myanmar <ul><li>Launched in 2004 </li></ul><ul><li>Passive case-finding model </li></ul><ul><li>Franchise of General Practitioners </li></ul><ul><li>in the private sector </li></ul><ul><li>Providers trained in TB symptomatic screening, diagnosis and treatment </li></ul><ul><li>Refer suspected TB cases to qualified labs </li></ul><ul><li>Treatment supporters provide follow-up to encourage adherence, trace clients who default on treatment and conduct contact tracing </li></ul><ul><li>PSI officers monitor quality assurance regularly </li></ul><ul><li>Demand creation through IPC and mass media </li></ul>
    8. 8. Results from Myanmar <ul><li>150 townships in 11 states </li></ul><ul><li>691 providers, 145 labs </li></ul><ul><li>116,849 clients tested for TB </li></ul><ul><li>53,890 registered TB cases </li></ul><ul><li>27,711 Category 1 cases </li></ul><ul><li>84% treatment success rate </li></ul><ul><li>10% contribution to national case detection rate </li></ul><ul><li>>55% of patients are from the lowest two socio-economic groups </li></ul>
    9. 9. GreenStar - Pakistan <ul><li>Launched in 2005 </li></ul><ul><li>Active case-finding by Community Health Officers </li></ul><ul><li>Door-to-door screening in high burden neighborhoods </li></ul><ul><li>Community-events for sputum collection </li></ul><ul><li>Private general practitioners trained in symptomatic screening, diagnosis and treatment </li></ul><ul><li>Referrals provided to qualified labs </li></ul><ul><li>Treatment supporters to encourage adherence, trace patients who default and to conduct contact tracing </li></ul><ul><li>QA visits from GreenStar project officers </li></ul>
    10. 10. Pakistan: GreenStar and TB <ul><li>1,080 providers, 49 labs </li></ul><ul><li>36,277 community-based treatment supporters trained </li></ul><ul><li>2,100,000 people reached </li></ul><ul><li>40,419 registered TB cases </li></ul><ul><li>89% treatment success rate </li></ul><ul><li>33-51% contribution to case detection rate in areas where it operates </li></ul>
    11. 11. TB Communications <ul><li>Where? </li></ul><ul><ul><li>Central Asia, India, Kenya, Laos, Myanmar and Romania </li></ul></ul><ul><li>What? </li></ul><ul><ul><li>TB (awareness, treatment seeking, adherence, etc.) </li></ul></ul><ul><ul><li>TB/HIV </li></ul></ul><ul><ul><li>Stigma </li></ul></ul>
    12. 12. PSI and TB/HIV <ul><li>Non-medical TB screening of HCT clients and referrals to laboratory diagnosis </li></ul><ul><ul><li>India, Mozambique, Myanmar, South Africa, Zambia, Zimbabwe </li></ul></ul>
    13. 13. South Africa: HIV/TB Integration <ul><li>Launched in 2006 </li></ul><ul><li>Mobile HIV counseling and testing (CT) for individuals from out-patient departments/TB wards </li></ul><ul><li>HIV-positive individuals referred back to clinic </li></ul><ul><li>July 2006 - Sept 2009, >7,000 patients tested for HIV </li></ul><ul><li>Among TB patients, 90% tested HIV-positive </li></ul><ul><li>80% of referrals tracked successfully </li></ul><ul><li>Telephone tracking ensures patients use referrals </li></ul>
    14. 14. Zimbabwe: HIV/TB Integration <ul><li>HCT Clinics perform symptomatic screening </li></ul><ul><li>Recently, clinics began offering sputum microscopy onsite </li></ul><ul><li>Individuals who are diagnosed with TB are referred to public health facilities for treatment </li></ul>
    15. 15. Next Steps <ul><li>Continued TB service delivery through existing franchises </li></ul><ul><ul><li>Scale-up of existing programs </li></ul></ul><ul><ul><li>Launch of new networks </li></ul></ul><ul><li>Support NTCPs and other partners in delivering evidence-based communications for TB and TB/HIV </li></ul><ul><li>Expand TB services offered within HCT clinics – including lab diagnostic services </li></ul><ul><li>Strengthen TB screening among PLWH by scaling up screening through HCT </li></ul><ul><li>Increase support to NTCPs to provide provider-initiated HIV counseling and testing to all TB suspects and patients </li></ul>
    16. 16. Thank you! <ul><li>For more information on PSI and TB </li></ul><ul><li>please contact: </li></ul><ul><li>Megan Elliott </li></ul><ul><li>[email_address] </li></ul>