KEY EXPERIENCES AND ACHIEVEMENTS
1. Research and Development:
The Association has been a technical partner of the National TB Control Programme in designing and carrying out a series of research and development activities to make effective the planning and implementation of DOTS strategy package in Pakistan. The main source of support for the research activities has been the Department for International Development (DFID) through its TB knowledge Programme. Following are the research activities that have been carried out during the year.
Who make the best treatment supporters for tuberculosis: outcomes from implementation of DOTS in Pakistan
Selection of best treatment supporter highly influences the better compliance to TB treatment. Patient friendly support needs to be the basis during the process of selecting treatment supporter.
The study informs the programme about more feasible treatment support options for wider use in the country.
This study of direct observation experiences in 12 districts was meant to provide further insight into treatment support processes and outcomes. The results of the study would help further refining the direct observation arrangements in programme context.
This was a retrospective study based on record review of 2929 new smear positive TB patients registered at 43 hospitals (district and sub-district hospitals and one teaching hospital) in 12 districts of Punjab province. The study was carried out during April 2004 and February 2005. A combination of quantitative and qualitative study methods was used.
The Qualitative part of the study provides in-depth information regarding attitude and perceptions of patients, treatment supporters and DOT facilitators. The quantative part provides analysis of treatment outcome according type treatment supporter. The key finding of the study was that the treatment outcome (i.e. treatment success rate and default) was significantly better in patients who were under the direct observation of treatment supporter (i.e. the Lady health workers/Community health workers) (Figure-2).
The study compares and discusses the patient outcome by gender, age and location (i.e. urban rural). The study also provides detailed analysis on Treatment adherence and treatment supporter preferences by patients (Fig-1). Important recommendations have been made to help the national TB control programme refining the direct observation arrangements in the country context.
Study on Fixed Dose Combinations
Fixed Dosed combination reduces the likely hood of the patients taking single drugs and contributing to drug resistance. There are fewer tablets to take and therefore easier for the patients, family members, as well as the treatment supporter to know if the correct drugs have been taken.
Under the support of DFID the study's main objective is to know the influence on the treatment outcomes of introducing Fixed Dose Combination (FDC) drugs as compared to the existing single Dose preparation.
The study was undertaken to evaluate whether the introduction of FDCs increases significantly (or not) the treatment outcome in new pulmonary smear positive patients compared to those on single drug combinations in the context of routine programme implementation in typical districts in Pakistan.
A combination of quantitative and qualitative study methods were used. Quantitative method was used to compare the treatment outcome (intermediary) results analyzed according to the type of drugs used (i.e. FDC versus single drugs) to treat the TB patients. Qualitative methods (in-depth interviews) were used to assess the affects of using FDCs on:
TB case management practices (i.e. Prescription, dosage, health education, side effects management and DO),
Drug management practices (i.e. procurement, storage, distribution and record keeping), and Patient perceptions. In-depth interviews were conducted with national, provincial and district managers, care providers (doctors/DOTs facilitator) and patients.
We prospectively reviewed records of 1125 new pulmonary TB patients from three districts (i.e. Jhang, Sahewal, Khanewal and Sheikhupura) of Punjab province from July to December 2005 (02 quarters). Out of these 924 patients were on FDC therapy and 201 on single TB drugs. Main variables included Number and proportion of new smear positive pulmonary TB cases and their treatment outcome (intermediary) in the FDC and single TB drugs administering tehsils of four districts. In-depth interviews were conducted with individuals belonging to three groups (i.e. patients, care providers and managers) to understand their perceptions.
The analysis of quantitative data showed that patient outcome (sputum smear conversion, transfer outs and non-conversion) at 8 weeks was significantly better in intervention tehsils (administering FDC therapy) as compared to control tehsils (administering single dose therapy (Fig-1)). The qualitative analysis showed that both the care providers as well as patients preferred FDC to single drugs. The preference was mainly due to the simplicity of treatment (i.e. reduced number of pills, decreased risk of incorrect prescriptions and better management of drug).
Analyzing the Context and Developing the Process for Public-private Partnership Development in TB Control
The National TB Control Programme is well aware of the importance of involving non-government sector providers for effective control of TB, through enhanced case detection and treatment success. The NTP has already coordinated a nationwide consultation process to formulate national strategic framework for public-private partnership development in TB control.
Preliminary groundwork was urgently required to enable the NTP to develop a set of context-sensitive operational strategies and implementation arrangements for already agreed strategic guidelines/framework. The Planning Commission suggested the Programme to develop these mechanisms on priority basis. The proposed set of nine-month research and GRIPP activities enables the Programme to take well considered/informed decisions about: Partner Identification, Enabling private providers and Enabling private laboratories.
Effectiveness of smear negative TB guidelines (Phase 4):
This study compares how smear negative patients are managed before and after the introduction of the new smear negative algorithm. This will show the change in proportions of each diagnostic category according to (or not) the care pathway included in the new algorithm. The implementation of the new guidelines will be investigate through measuring process indicators & other qualitative techniques and assess the change using the routinely collected data in the programme.
The TB Control Programme Pakistan is currently implementing the DOTS strategy in the various districts using the newly developed WHO TB case management guidelines and training materials. One such district will be selected for the implementation of new smear negative TB guidelines and would act as a intervention district. All doctors working in the diagnostic centers of the intervention district will be given a refresher session on the existing case management protocols. In addition the doctors will be given training session on the new guidelines for diagnosing a smear-negative TB case. The training package will be evaluated for quality within the training session. After the training session, the doctors of the district will be requested to adopt from that day onward, the new guidelines in their practice.
The guidelines for diagnosing and managing a smear-negative TB cases, will be introduced in the diagnostic centers in the intervention district. After 3-6 months of the implementation of the new guidelines, key informants (doctors & other healthcare workers involved in the delivery of care) will be interviewed in-depth. This will help the researchers to direct their interview and to understand the barriers and facilitators in the implementation of the new guidelines
GFATM III (TAF / ASD)
The Asia Foundation (TAF) was approved a project by GFATM in round 3. The purpose of the project is to complete the efforts of the National TB control Programme (NTP) in addressing the two core issues of case detection and cure rates. The objective of this project is ‘to develop and implement an interactive community mobilization strategy for achieving 70% case detection and 85% cure rate. ASD with its technical partner TAF (The Asia Foundation) jointly worked under GFATM III project. ASD with its in-depth understanding of TB programme strategies and operations and experience in health systems development jointly analyzed the situation and accordingly develop operational guidelines and materials for implementation of the project activities. The key activities, which ASD assisted, TAF includes:
Establish project implementation unit
BCC through interactive theater approach
Establish network of trained community volunteers in districts
Social rehabilitation of TB patients
Develop incentives for patients and family members
Nuffield led consortium
Nuffield led consortium has awarded a five-year programme to the association for research on communicable diseases in Pakistan and other developing countries including Bangladesh, China, Ghana etc. The consortium activities started from April 2006. The aim of the communicable disease (COMDIS) research programme consortium is to ensure access to effective interventions on a far greater scale and reaching vulnerable people.
It will investigate patient and provider issues and evaluate approaches to improve utilization, delivery and quality of interventions together with health systems issues. A key strategy will be to anchor research within operational programmes, so that knowledge will be rapidly incorporated into policy and practice at scale in partner countries and elsewhere.
Fund for Innovative DOTS Expansion through Local Initiative to Stop TB (FIDELIS), through an international competition in round-IV, awarded a one-year project for Introducing and strengthening DOTS in four districts of Punjab and NWFP, through public-private partnership.
The goal of this project is to reduce the burden of tuberculosis in four districts of Punjab and NWFP (Faisalabad, Bahawalpur, Abbottabad and Mansehra), by introducing and strengthening DOTS in a network of public sector primary, secondary and teaching level health facilities.
The project had two main components interventions, i.e. “Strengthening public health services and Community mobilization”
The first step was to facilitate workshops to review and plan the enhanced DOTS
implementation in each district.
The plan covered the areas: training of care providers and managers, procurement and logistic support, monitoring and supervision, data management strengthening.
Project staff in partnership with PTP also carried out a two-day workshop. This exercise provided the participants an opportunity to review the situation, formulate implementation plans, and agree on respective roles and arrangements. The product of the workshop was a detailed plan including training, logistics and drugs, quality control, monitoring and supervision, etc.
NTP training materials and PTP trainers were used to train various categories of health personnel in four districts.
A total of 78 diagnostic centers are established in project areas. Out of these 40 are likely to require a binocular microscope each.
Each diagnostic center received regular onsite technical support to put in place the Programme arrangements/operations through Central Coordinator, Cluster Coordinator and District Lab supervisor. A District Lab Supervisor (DLS) in each district was trained in supervision of AFB examination and recording/reporting practices. Each DLS was also provided a motorcycle for onsite technical support to the DOTS Facilitator and laboratory person at the diagnostic centers.
This photo captures the event of community mobilization in which DLS (district Laboratory supervisor) Sheikhupura is communicating with the peoplein the mosque.
The participating facilities followed the NTP guidelines for screening, diagnosis, patient registration, and decentralized drug delivery.
The proposed set of health services strengthening activities enhanced the capacity of four district health offices, 35 hospitals and 43 rural health centers, as well as 265 BHU/GRD to deliver and manage DOTS according to NTP guidelines
Community mobilization (LHW):
Community mobilization is considered critical for improved quality, enhanced utilization and optimal outcome of preventive and curative services. The project, in partnership with Programme, enabled four key agents to mobilize communities in 4 districts.
The mobilization agents that were to be enabled are:
400 school teachers from high schools and middle schools,
3500 community health workers,
200 local religious leaders, and
40 local journalists.
i) 400 teachers from 200 selected higher and secondary schools were enabled, in partnership with district education office, to mainstream the TB control in their respective institutions. These trained teachers disseminate messages to their peers (teachers) and students, with the help of standardized communication materials.
ii) The project staff oriented focal persons at health facilities. The focal persons, with the help of project staff, then trained 3500 lady health workers associated with the facilities. The trained lady health workers were also provided with communication materials to facilitate their communication with potential clients in their respective communities. The enabled lady health workers make use of existing interaction avenues to raise their awareness as well as involvement in TB control activities.
The interaction avenues included: meetings of village health committees, and individual conversation at health house and household level.
A community mobilization event was organized in district Khanewal under FIDELIS V. In this picture Dr. Nayyar along with DTC Khanewal is orienting LHW's (lady health workers) about TB services initiated in Khanewal district in the community mobilization
iii) The project staff mapped the religious institutions (i.e. religious schools and mosques). In each district five institutions were selected and from each selected institution one religious leader was enabled. Each of these enabled religious institutions arranged an orientation session for a group of ten peers (religious leaders). The enabled religious leaders will help to fight against TB associated stigma.
iv) The project staff, in partnership with district health and education offices as well as representative body of journalists, coordinated an orientation session for ten selected journalists in each district. These journalists encouraged to use print media for disseminating messages to their respective readers.
Dr. Sven's visit:
Dr. Sven for his quarterly monitoring visited Pakistan in ___ 05 he visited Rural Health Center Noor Shah at district Sahewal. In this picture Dr. Sven along with project and regional coordinator are discussing the findings with the doctor at Rural Health Center (RHC) Noor Shah.
2. Capacity Building:
Development of guidelines and training material for malaria control program under GFATM II:
Under GFATM round II project ASD developed guidelines and training material for National malaria control programme (MCP) and these training material includes:
Malaria Case management: Training manual
Malaria Case Management: Desk guide for doctors
Malaria Case Management: Facilitator guide
Programme Monitoring Malaria Case management: Training Manual
Programme Monitoring Malaria Case management: Guide line
Programme Monitoring Malaria Case management: Facilitator Guide
Malaria Microscopy: Training Manual (English)
Malaria Microscopy: Training Manual (Urdu)
Malaria Microscopy: Desk Guide (English)
Malaria Microscopy: Desk Guide (English)
Malaria Microscopy: Facilitator Guide
These materials are used in different trainings all over Pakistan.
Lab Technician training:
With the partnership of Malaria control programme (MCP) ASD organized
‘Lab technician training, on Malaria microscopy' (Aug 29, 2005 - Sep 7, 2005). This lab technician training was supported by GFATM (Global Fund Against Tuberculosis and Malaria. In this training of technician above mentioned ASD developed modules were used.