Partnering for Results in Post-Conflict Countries

Friday’s symposium dealt with, “Saving lives in areas of conflict or disaster: partnering for results.” Dr. Eliud Wandwalo (MSH Tanzania) coordinated the session along with Morgan Richardson (USA). First up was Dr. Joseph Lou (South Sudan’s National Tuberculosis Program [NTP]), who explained the challenges that remain in the health facility infrastructure in his presentation entitled, Partnership for DOTS expansion in post-conflict situations: experience from South Sudan.

Following his presentation, Dr. Stephen Macharia (MSH TB CARE I-South Sudan) spoke about Integrating TB into primary health care in South Sudan: challenges and lessons learnt. His presentation clearly laid out the challenges that they have faced and what they have done so far to tackle them. Although they have renovated some health facilities, other factors, like lack of human resources and unsafe transportation, remain. Often times, an activity that should take only two days, takes up to one week, because of transportation issues (i.e. plane getting stuck in mud). Dr. Macharia also explained that there is still a lot of stigma around TB among health care workers, poor access to health services, and inadequate and poor quality of health services. He also mentioned that in order to access health facilities, sometimes people have to wade through water for up to two kilometers- this does not work well for constant supervision and monitoring.

About 75% of 1147 functional health facilities require renovation or reconstruction. Facility coverage on TB services is only 22% of 345 hospitals and primary health care centers. Most of the health facilities providing TB services are concentrated in the urban centers. Assessment conducted in 2011 showed that 46% of the functional health facilities meet minimum criteria to integrate TB services. This is an opportunity for TB services scale up in the country. Despite the challenges of human resources and infrastructure, minimum funds can be mobilized to refurbish health facilities and provide supplies to establish TB services. Training of existing health workers and community involvement is a key to integrate TB services into primary health care.

Moving from South Sudan to Afghanistan, Dr. Mohammad Khakerah Rashidi (MSH TB CARE I-Afghanistan) spoke about Community contribution in TB control in Afghanistan. There are roughly 24 million people in Afghanistan and it is one of the 22 high burden TB countries in the world. Dr. Rashidi explained that the female to male TB ratio is 2:1, thus, they trained 156 female health workers in their standard operating procedures (SOPs) and engaged 4,000 female community health worker (CHWs) in community-based Directly Observed Treatment, Short-course (CB-DOTS). They implemented this CB-DOTS approach by contracting with NGOs and holding raising awareness during community events. This resulted in improved surveillance (addition of indicators for females). The team also promoted a multi-sectoral organization approach to TB by involving the Ministry of Women’s Affairs and the Ministry of Education.

Although this is a success to be proud of, there are many challenges that remain: There is a lot of stigma and discrimination against people with TB in Afghanistan, as in South Sudan; females are rarely allowed to visit health facilities (a cultural issue); and there is poor TB treatment adherence. In addition, there is insecurity, lack of awareness about TB in children, poorly educated CHWs, no payment for CHWs (volunteers), and few people supervising and monitoring over 4,500 health posts in Afghanistan.

TB services must be supported by the communities they serve to attain sustainability. By actively engaging a diverse range of actors in TB control activities and dividing responsibilities clearly among them, programs can expand and strengthen their responses to difficult TB control challenges.

Swetha Desai, Project Specialist for TB CARE I and TB-IQC, contributed to the content of this story.

Transitioning to Sustainable Pharmaceutical Management Systems for TB

Today marked the 10th year the USAID-funded, MSH-led Systems for Improved Access to Pharmaceuticals and Services Program (SIAPS), in collaboration with The Global Drug Facility (GDF), an arm of the Stop TB partnership, conducted a pharmaceutical management systems workshop at the Union World Conference on Lung Health.

MSH/SIAPS and GDF shared experiences, strategies and tools for improving and sustaining pharmaceutical management systems from global, regional, national, facility, and patient perspectives (read workshop description).

The Global Perspective

Kaspars Lunte (GDF, Geneva) described 10 years of GDF experience with partnerships for increasing sustainable quality assured anti-TB medicines. If dedicated funding is available, GDF is positioned to double its number of patient treatments to 50,000 and deliver treatment for all global cases enrolled by 2015.

National Perspectives

  • Brazil: Margateth Dalcolmo (Director of the Helio Fraga Reference Center for TB, Fiocruz/Ministry of Health Brazil) reported on Brazil’s experience implementing SIAPS’s web-based tool for pharmaceutical management systems, e-TB Manager. With technical assistance from SIAPS during the pilot and implementation phases, the system is now maintained by Brazil’s TB program, thus working towards its long-term sustainability.
  • Rwanda: Alaine Nyaruhirira (MSH, Rwanda) outlined financing requirements needed to roll-out Xpert MTB/RIF under the extended National TB Control’s strategic plan. Attendants learned of the importance for TB programs to identify the connection between plans and budgets for treatment and diagnostics in determining financing requirements to sustain new interventions.

A Regional Perspective – Eastern Europe and Central Asia

Archil Salakaia (SIAPS, USA) presented challenges and lessons learned from developing partnership frameworks to improve TB information systems in Ukraine, Uzbekistan, Azerbaijan, Armenia, and Georgia. The presentation focused on lessons learned from the process of implementing e-TB Manager in the Eastern Europe and Central Asia region. New developments, for example the laboratory module for e-TB Manager, also were presented.

A Facility Perspective – Three Models for Public Private Mix (PPM)

  • Pakistan: Ayyaz Kiani (MOH, Pakistan) described the potential for 45,000 to 50,000 retail medicine outlets in Pakistan to facilitate early identification of clients with TB-like symptoms for referral to TB diagnostic centers for diagnosis and adequate treatment.
  • Tanzania: Salama Mwatawala (MSH, Tanzania) described how pharmacists and Accredited Drug Dispensing Outlet (ADDO) dispensers can contribute to current global and national initiatives which encourage the use of “public/private mix” approaches to increase TB case detection.
  • Kenya: Jerimiah Chakaya (Kenya Association for the Prevention of TB and Lung Disease – KAPTLD) described the highs and lows of 50 years engaging the private sector in Kenya’s TB control program.

Lessons learned from the three speakers’ presentations included the importance of training private practitioners in methods of TB case detection and referral, the importance of considering traditional healers as private practitioners, and to “Keep Calm, Carry On” – persistence and passion lead to success and sustainability.

The Patient Perspective

Antonia Kwiecien (SIAPS, USA) presented a tool developed by SIAPS to assist NTPs in developing a Drug Utilization Program for Second-line Drugs. Attendants learned that including a sustained Drug Utilization Review program in a National TB program can ensure patients receive appropriate drug therapy and optimal therapy outcome.

Looking Forward to The Post-2015 TB Strategy

Andre Zagorski (SIAPS, USA) summarized the workshop, emphasizing that we are all facing new challenges in terms of pharmaceutical systems management: scaling-up MDR-TB treatment, and developing new drugs and diagnostics. He thanked participants for their active engagement in the workshop.

Antonia Kwiecien, Senior Technical Advisor, SIAPS USA, contributed to this story.