The SOLUCION TB Program in Mexico from 2004-2012 worked to strengthen tuberculosis control through several phases. It began with dedicated programs in two states, then expanded nationwide working in 13 states and 35 municipalities. Key strategies included advocacy, communication, social mobilization, and training healthcare workers. Results showed improved TB treatment success rates and collaboration between health agencies and communities. Later phases addressed comorbidities of TB-HIV/AIDS and TB-diabetes by improving testing, diagnosis, and referrals. The program strengthened public health systems and informed national TB strategies in Mexico.

1. The SOLUCION TB
Program in Mexico
Strategies and learning from a systems-
strengthening program to improve
Tuberculosis control in Mexico
2004-2012
CORE Group Spring Meeting
TB and HIV/AIDS Working Group Session
April 240, 2013

2. The SOLUCION TB Program
experience
• SOLUCION TB was a collaborative TB prevention and
control 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 (Tijuana
and Mexicali), funded via the CSHGP
– Phase 2 –expansion phase, reaching 13 states
(including Baja) and 35 municipalities
– Phase 3 –piloting of a comorbidities program addressing
TB-HIV/AIDS and TB-Diabetes. Reduced funding and
scope
– Phase 4 –continuation of the comorbidities program
• Results include strengthening of public health system in
Mexico with improved TB control outcomes

3. Basic info on TB and needs in
Mexico
• 2012: Over 19,700 cases (all
forms), 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 some
regions as high as 48)

4. Basic info on TB and needs in
Mexico
• The country has strong norms and lab systems, and
continuous supply of medication and testing materials.
• Varied levels of leadership, management capacity and
training of staff. Stigma and discrimination are present.
• Health center staff delivering services for 20+ priority
programs
• Insufficient awareness about TB basic symptoms and
high levels of misinformation and myths.

5. SOLUCION TB: Phase 1 (CS)
• 100% TB Child Survival Grant
• Work in Tijuana and Mexicali municipalities to
improve TB treatment success
• increased number of dedicated TB staff,
improved training and community
engagement trough community health
workers
• Despite change in national level leadership,
cultivated a strong working partnership with
USAID and the NTP
• Results: improved treatment success rates
and decreased treatment default; improved
collaboration between MOH and affected
communities
• Due to good results, a request for expansion
received

6. SOLUCION TB Expansion
Strategies (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. SOLUCION TB Expansion –key
challenges
• Lack of awareness about
ACSM
• ‘Silo’ design with little or no
collaboration with related
departments (Lab, health
promotion, social
communication, etc.)
• Lack of experience working
with communities (and vice
versa)
• Highly medicalized model,
with pre-conceived attitudes
about persons with the
disease

8. SOLUCION TB Expansion Model
Recruitment, training and deployment of
dedicated TB staff (DOTS workers mainly)
Advocacy, Communication
and Social Mobilization
Capacities for: health personnel,
PTB and affected communities
MOH
Strengthenning
DOTS workers
ACSM
PATB

9. SOLUCION TB Expansion
locations
Cd. Juárez
Chihuahua
Creel
Torreón
Saltillo
Monclova Monterrey
Guadalupe
Hidalgo
Sta. Catarina
Reynosa
Matamoros
Tampico
Veracruz
Poza Rica
Coatzacoalcos
Tuxtla
Tapachula
Comitán
Costa, Istmo, Tuxtepec
Acapulco
Lázaro Cárdenas
Apatzingan
Morelia
Zapopan
Tlaquepaque
Guadalajara
Zacatecas
Ojocaliente
Fresnillo
Tijuana
Santa Ana
Caborca

10. Advocacy, Communication and
Social Mobilization (ACSM)
• Participatory planning -
assessing strengths and areas of
improvement through I-STAR
(nationally and in the 13
states/35 jurisdictions)
• ACSM training to build MOH
capacity in ACSM strategies
• Moving beyond theory – lack of
information on “how to”
• ACSM planning included purpose
and measuring objectives
• Innovations:
– Empowering DOTS
– Internal and external ACSM
– Greater Participation of People
Affected
– Changed language (from
patient to person affected) to
influence attitudes/behaviors
– Utilization of Voices and
Images (Photovoice) and
testimonials

11. Expansion: Main Results and
products
• Achieved 91.2% treatment cure rate
(85% MOH target) and 0.8% treatment
default, for target participants in the
35 jurisdictions
• 3.8 million reached through 3,000
ACSM activities and events (including
56,971 community members directly
participating)
• 48% staff absorption by MOH (from
127 TB workers hired/deployed)
• First Knowledge, Attitudes and
Practices, and first TB Stigma studies
in the country
• Mexico’s work highlighted in the STOP
TB first ACSM promising practices
publication
• Improved data (cohort) analysis and
decision-making

12. Expansion: Main Results and
Products
• Facilitated inclusion of ACSM strategies into TB prevention
and control strategies (new position at NTP and 2 states),
ACSM plans
• Increased visibility of stigma and discrimination and raised
importance of mitigation strategies
– 8 Voices and Images galleries produced and touring
exhibits
– Nuestra Casa exhibits: 7 exhibits (UTEP, Cancun, Oaxaca,
Reynosa, Tijuana, Atlanta and UTEP)
– Educational pieces on rights and responsibilities, and
myths and realities (brochure and video)
– Luchando Por Una Voz power points (photo journals of
people with TB)

13. Voices and Images and Nuestra
Casa
“Loneliness in TB”
Alejandro, 19
“Is your heart like this?”
Alma, mother to Marianita
Nuestra Casa Exhibit

14. SOLUCION TB Expansion –key
lessons learned
• Integration of strategies that ‘humanize’ the disease were
key to transforming disease-based to person-centered care
-changed language influencing attitudes
-identification and mitigation of stigma, listening to those
affected
• Internal ACSM took place before working with external
audiences
– empowering of TB staff
• Invested where needs in service-delivery were greater:
– health centers and jurisdictions (municipalities)
• Change supported through improved communication and
coordination (face-to-face regional meetings twice per year;
‘organic’ mentoring/support; monthly online newsletters)

15. Phase 3 –piloting of
comorbidities model Jan-Sep
2010
Proposal based on cohort analysis in previous
phases 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, used
compelling, convincing evidence
• Initial national training for 7 states (including
one jurisdiction)
• Comorbidity plans established to improve
comorbidity testing, diagnosis and referrals
• Clear identification of challenges to integration
of detection and referrals
• Phase 4 model designed

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 facilitate
documentation and improve reporting
• New awareness and educational pieces developed to
integrate messaging
• Monthly follow-up and bi-annual regional workshops
Raising the profile and credibility of the TB program was both
an outcome and a strategy for fostering greater
collaboration with the other 2 programs.

17. SOLUCION TB comorbidities
model: joint planning and
implementation
Awareness, testing and referrals of TB (and
Diabetes). IPT.
Awareness, Testing and
referrals; DM case
management for TB-DM.
Awareness, testing and
referrals. Supports DM case
management targets.
SSA
TB
HIV/AIDS
Diabetes
PATB, VIH
y DM

18. Phase 4 Main Results: Clinical
– Prevalence of HIV/AIDS-TB co-infection
increased 154% between 2007 and 2011
(8.5% previous 4 year period). TB-DM
prevalence increased 73%
– Testing of HIV in TB increased 71%,
testing for DM in TB increased 73%
– 96% of people with HIV received info on
TB
– Screened 25,089* persons with TB,
HIV/AIDS or Diabetes (~790/month)
– 68% of individuals with TB document HIV
test
– 4,582* MOH staff (physicians, nurses, lab
technicians and health promotion
workers) trained in co-morbidities
– Mexico a pioneer in TB-Diabetes work in
the Americas

19. Phase 4 Main Results: Systems
• Comorbidities information system needs
identified (to be ‘incorporated’ into new data-
base when available)
• Testing for HIV in TB and for TB in HIV
elevated to ‘indicators of excellence’ .
• Comorbidities positions created at national
level (and replicated in two states) to include
HIV/AIDS and Diabetes
• First joint co-morbidity monitoring pilot-tested
by HIV/AIDS, TB and Diabetes programs
• National and state training platforms now
include comorbidities learning
• HIV/AIDS-TB and Diabetes-TB experts
resulted in: a) key recommendations widely
distributed, b) modification of ARV guide, and
c) revision of new TB national Norm

20. Challenges and Lessons Learned
• In spite of independent design and operation, integration of referral
services at referral is possible and necessary
• Modified information systems to make comorbidities work visible and
measurably contribute to sustaining results
– At all levels: from identification of indicators to formats to be used at
the health clinic level.
• Ongoing, quality training is necessary, and should be supported through
follow-up on-site visits
– Quality training includes peer sharing and learning (cross training),
connecting planning with training, utilizing a needs-based and state
of the art information sharing approach, and combination with
hands-on application and follow-up
• Successes built upon previous phases (including person-centered
approach, 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. Additional
analysis needed to determine how much recommendations from expert
summits contribute to improve it

21. Key challenges that remain
TB-HIV/AIDS
• Inconsistent clinical
guidelines for use of IPT
• Lack of collaboration with
(and fear of) communities
and NGOs
TB-Diabetes
• Burden of DM (volume of
people with DM
• Those who might need it* the
most are not accessing health
services
• Consistency of expansion/dissemination of
comorbidity model
• Inclusion of comorbidity indicators into new health
information system (TBD)

22. The way forward
• MOH is committed to
sustaining results
– MOH requiring states to
continue/adopt the models;
national training; ongoing
sharing of tools; etc.
• Collaboration between
HIV/AIDS, Diabetes and
Tuberculosis programs to be
expanded nationally
• New information system to be
developed by MOH to
incorporate key indicators
• PCI to disseminate and
replicate systems-
strengthening/integration
model in other countries

23. Testimonials
• “PCI represented a
breakthrough for
Tuberculosis (TB)control in
México. A person-centered
approach to service
delivery, improved
awareness of the disease,
and improved co-morbidity
services for TB-HIV/AIDS
and TB-diabetes are direct
results of this partnership.”
• Dr. Martín Castellanos Joya,
Director, National Tuberculosis
Program, Ministry of Health,
México
• “We are really pleased with the
achievements of this program
which has focused on
coordination and collaboration
among the institutions that
handle HIV/AIDS, TB, and
diabetes. The program has
improved services provided to
patients; systems of strategic
information; and diagnosis and
treatment. We are satisfied that
the program has exceeded its
goals. I hope that Mexico
considers the success of this
truly Mexican program as an
important complement to all
the efforts in the country
fighting against TB.”
• Sean Jones, Deputy Director,
USAID México

24. Thank You!
• More information? please contact:
• Blanca Lomeli
• blomeli@pciglobal.org
• Or Jessica Chen
• jchen@pciglobal.org
• 858 279 9690
• PCIGlobal.org
• SOLUCIONTB.org