ACSM Best Practice

Country: Dominican RepublicPresenter Name: Luis Alberto Rodríguez Reyes

Organization: KNCVDate: November 2012

• History and experience: leading the fight against TB since 1903. Co-founder and co-developer of the standardized and WHO-recommended global TB control method (DOTS) and, through research, many evidence based globally recognized principles.

• Over a century’s involvement in Dutch TB control: since its foundation KNCV Tuberculosis

• Foundation has played a key coordinating role in TB control in the Netherlands.• Exclusively specialized in TB. • Authority and reputation: one of the leading international players and a respected

national and international partner (of WHO, USAID, CIb, donors, technical agencies, and ministries of health etc.) in TB control

• Saving lives. • Center for comprehensive expertise and knowledge-sharing on TB control.• Leading a prominent international coalition.• Focus on capacity building of countries.• Local presence.• Global guidelines and policy making. • Strengthening Health Systems.• Comprehensive package: we provide a package approach to TB control, embracing a

comprehensive set of measures to strengthen health services and implement TB control programs.

• Royal: awarded a royal title in 1953…

TB Situation in Your Country*

• Prevalence: 45 x 100,000 Hab. (2011)

• Incidence: 25 x 100,000 Hab. (2011)

• Mortality due to TB: 1.2 x 100,000 Hab. (2010)

• TB/HIV co-infection: 18.1 % (2011)

• MDR-TB: 120 confirmed cases (2011)

Source: National TB Program, Epidemiological Surveillance Unit NTP.

0-14 15-24 25-34 35-44 45-54 55-64 65 y masvarones (tasa) 0.51 6.45 8.96 8 4.65 2.4 1.89mujeres (tasa) 0.59 5.11 4.97 3.57 2.11 1.08 0.88varones (No.) 23 290 403 362 209 108 85mujeres (No.) 29 249 242 174 103 53 43

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.No. de Casos y Tasa de Incidencia TB BK (+) por Sexo,

Republica Dominicana, 2011Number cases and Incidence of TB BK+ by gender, Dominican Republic, 2011

Source: National TB Program, Epidemiological Surveillance Unit NTP.

NTP Goal & Objectives 1*

• Goal.Reduce morbidity and mortality due to TB by 50% in relation to 1990 country rates through the strengthening of the NTP based in the Stop TB Strategy.

• Objectives. 1. Place TB in the National Political Agenda at the highest level.

Source: National Strategic Plan, NTP.

NTP Goal & Objectives 2*2. Expand and improve DOTS services with quality in the National Health System, with emphasis in most at risk groups.3. Improve health care to TB/HIV coinfected patients.4. Prevent and control MDR TB.5. Strengthen the community involvement in the National Response to TB, through the aplication of ACSM strategies.- Integration of most affected communities in TB control activities.- Design and implementation of ACSM strategies to involve CBO.- Activation and Strengthening of Stop TB Committees.

6. Promote research and use the results for the decision making. Source: National Strategic Plan, NTP.

TB Control Challenge(s)• Low detection of TB suspects.

– Majority of the population does not indentifies signs of pumunary TB, cough hygine and cough is socially accepted.

• Late diagnose of TB cases.• Stigma and discrimination of TB patients.• Low treatment success rate.• Need to improve capacity building.• Weakness in managerial activities (supervision, M&E).• Limited capacity for data analysis.• Inefficient referral system.

Source: National Strategic Plan, NTP.

About Your Project

Source: National Strategic Plan, NTP.

About Your Project 2*Technical Areas:

1. Universal and early access

• ACSM: Community involvement

2. Infection Control (IC)

3. Programmatic Management of Drug Resistant TB (PMDT)

4. Health Systems Strengthening (HSS)

• Capacity Building

• Supervision

5. M&E, Operations Research (OR) and surveillance

Source: TB CARE I work plan.

Why involve the community?

• Need to DELIVER DOTS– Medication is available, but patients

do NOT come to get treatment.• Raise awareness• Reduce Stigma and Discrimination

Increase Case Detection

Low case detection in known high prevalence areas.

What did we do in the DR?• Mapping the neigborhoods: Slums – Gualey (Area IV)

– Identify high risk groups: Geographic areas– Poorest of the poor…– Identify partners: CBO´s, FBO´s, Private sector, HCP,

Community leaders, etc.• Other Criteria, communities with high prevalence of:

– Violence– HIV– Alcoholism– Poverty

• Overcrowding

Devlopment of a Plan• Action Oriented• Not Recipes• Laying the groundwork• Bottoms- up• Kick off meeting:

– Sensitization– Epidemilogy– Risks factors– Group work:

• Brainstorming• Collaboration

COMMUNICATION comes from the Latin word "communicare" meaning to share.

Enabling environment to promote empowerment…

• Providing information about the risk factors in their location.

• Adapting the speech according to the public (flexible according to the audience: women, persons deprived of their liberty, drug users, etc).

• Providing examples of what things are possible to be done:– Showing pictures of activities made by other

communities.• “Transferring” the responsibility of providing

guidance on what to do.• Communities define their priorities.

What would you do to Stop TB? • What can be done in your community to Stop the

TB?

Conformation of Community Stop TB Committees

Group of people that are committed and organized, that have developed a work plan to implement Stop TB activities in their communities with their "own resources”.

– Mission: active, early and timely search of TB suspects.

– Sustain TB awareness and change individual and social behavior around TB (decrease stigma)

baseline data before project started N/AObjective Actions Indicator* 2011 2013 TB CARE I

(by the end of 2012)Strengthen the community involvement in the National Response to TB, through the aplication of ACSM strategies

Integration of most affected communities in TB control activities

Porcentage of prioritized communities participating in TB Control activities

20% 40% TBD

Design and implementation of ACSM strategies to involve CBO

Number of CBO, FBO that participate in ACSM interventions for TB Control

380 570 363

Activation and Strengthening of Stop TB Committees

Number of Stop TB Committees

50 100 69

Source: National Strategic Plan NTP + TB CARE I reports. *National goals.

ACSM Activities 1 Conformation of Stop TB Comittees.

Involvement of schools.

Integration of Pharmacies in TB Detection.

Development of photo based strategy: Photovoices.– Raise TB awarness.

– Reduce TB related stigma and discrimination.

– Sensitization of middle and high level politicians.

TB information Hotline.

Integration of the National Postal Service: “Messengers for Health”.

Involvement of health journalists.

Development of IEC materials for IC.

ACSM Activities 21. Conformation of Stop TB Comittees:

- Community Model (leaded by communty)- Urban and Rural areas

- Activities:- IEC activities

- Increase TB Suspects detection

- Raise Awareness

- Hospital Model (leaded by HCW)- Improve quality of services

- Provincial Model- Political level

- Fund raising??

ACSM “Outcomes”

• +1,500 members of the Stop TB Committees (community leaders) trained in TB control related topics.

• +1,200 HCW trained in the Stop TB Strategy in project selected provinces.

• +1,000 HCW sensitized to promote and participate in the activities of the Stop TB Committees.

Intervention Outcome Remarks Challenges Next Steps

Stop TB Comittees +50 (projection is 69 by the end of 2012)

Model being implemented by NTP Local Coordinators.

Expansion of the model. Global Fund model is different. Availability of funds.

Data analysis. Negotiation with GF and partners.

2 Committees in Prisons

Leaded by interns Consolidation of the model in other prisons

Work with authorities to develop an agreement (Public-Public alliance)

5 Hospitals Committees

Leaded by HCW Better coordination with community leaders

Workshops to define strategy with HCW, community leaders and NTP local Coordinators.

2 provincial Stop TB Committees

Performs at a Political Level

Involvement of middle and high level politicians

Fund raising, formal request of legal budget % for health related issues from local governments.

ACSM Outcomes

Province Number of Committees

Number of Health Care Facilities

Number TB Suspects in HCF related to Committees2011

Number TB Suspects in HCF related to Committees2012

Santo Domingo 21 102 TBD TBD

Monte Plata 5 34 314 363Santiago 2 N/A TBD TBD

Neyba 3 N/A TBD TBD

Puerto Plata 4 N/A TBD TBD

Azua 9 12 217 662Elías Piña 3 N/A TBD TBD

ACSM Outcomes

During 2011 training and supervision made possible the implementation of DOTS in all Health Care Services in Monte Plata province. The number of TB Suspects that received lab test (baciloscopy) increased from 77.71% to 90.9%, and the number of TB Cases detected raised from 7 to 24 cases; Eleven cases were detected in six of the newly incorporated health care facilities that also are linked to the Stop TB Committees. In 2012 an increase of 28 sites (34 total) are reporting to the NTP TB Suspects and/or TB Cases.

Province MP

Number of Committees

5

Number of Health Care Facilities

34

Number TB Suspects detected in HCF related to Committees2011

314

Number TB Suspects detected in HCF related to Committees2012

363

Received Lab Test 2011

77%

Received Lab Test 2012

91%

Province AzuaNumber of Committees

9

Number of Health Care Facilities

12

Number TB Suspects detected in HCF related to Committees2011

217

Number TB Suspects detected in HCF related to Committees2012

662

Achievements• MoH Province Directors and NTP local Coordinators

empowered, implementing ACSM activities, in project selected provinces.– MoH Province Directors requesting support for the implementation

of ACSM activities.– Project was conducting the conformation of committees during first

year, by the second year project has focused in capacity building.

• Photovoices: “INVISIBLES” Photo exhibit: 8 displays in 4 provinces, including high political institutions (The Congress, MoH, MC, SIUBEN, National Postal Service).

Lessons learned• Identification of community leaders facilitates the conformation of the Community Stop

TB Committees.

• Enable the enviroment to promote empowerment.

• Coordinate with the HCW related to the communities in which the Committees operate, guarantees the sustainability of these interventions.

• Promote the integration of the authorities such as Provincial MoH Directors, NTP local coordinators, and other Governmental agencies.

• Promote the integration of the decision makers, private sector and other “non-health related” organizations.

• Community involvement requires that programs and/or projects provide a Comprehensive package:

– Provide a package approach to TB control, embracing a comprehensive set of measures to strengthen health services

– Enabling an environment in which the community can develop their capacities.

Lessons learned• Identification of community leaders facilitates the conformation of the Community Stop

TB Committees.

• Enable the enviroment to promote empowerment.

• Coordinate with the HCW related to the communities in which the Committees operate, guarantees the sustainability of these interventions.

• Promote the integration of the authorities such as Provincial MoH Directors, NTP local coordinators, and other Governmental agencies.

• Promote the integration of the decision makers, private sector and other “non-health related” organizations.

• Community involvement requires that programs and/or projects provide a Comprehensive package:

– Provide a package approach to TB control, embracing a comprehensive set of measures to strengthen health services

– Enabling an environment in which the community can develop their capacities.

Lessons learned• There is evidence of the referrals from the

Community Stop TB Committees, however the referral system and the M&E system is weak.

THANK YOU FOR YOUR ATTENTIONQUESTIONS/COMMENTS???

Acknowledgements