03 Jun India: Ashakalp Healthcare Association improves TB case notification among tribal groups
[vc_row css_animation=”” row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” angled_section=”no” text_align=”left” background_image_as_pattern=”without_pattern”][vc_column][vc_separator type=”normal” thickness=”2″ up=”20″ down=”20″][/vc_column][/vc_row][vc_row css_animation=”” row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” angled_section=”no” text_align=”left” background_image_as_pattern=”without_pattern”][vc_column][vc_gallery type=”nivo” interval=”3″ images=”2761,2762″ img_size=”full”][vc_column_text]The Sahariya tribal group in India has one of the highest TB prevalence rates in the country and faces severe barriers to accessing TB services due to economic, social and educational factors. As a result, they continue to suffer from this disease while NTP notification rates remain suboptimal.
Ashakalp Healthcare Association (AHA) has established a community outreach project to close the gap between availability and accessibility of TB services within the Revised National TB Control Program (RNTCP) in India. In order to do this, community health workers (CHWs) carry out active case finding activities for a year in specific catchment areas. They perform house-to-house TB symptom screening and collect morning and spot sputum samples that are then transported to the nearest laboratory for microscopy or Xpert examination. CHWs link confirmed TB patients to treatment facilities and provide counseling for them and their families.
With funding from Stop TB Partnership’s TB REACH wave 5, the project worked in 6 treatment units (TUs) of Madhya Pradesh: Dabra, Bhitarwar and Mohna in Gwalior district and Pohri, Pichhore and Khaniyadhana in Shivpuri district. The main target was the Sahariya tribal group in Madhya Pradesh, which has a reported TB prevalence of over 3’000/100’000. Other tribal groups such as Gondi, Mana, Halbi, Pradhan and Madia were also largely targeted by the scale-up intervention in Maharashtra.
The project improved case notification significantly in the 6 TUs. A total of 196’239 people were screened, out of which 12’362 showed TB symptoms. Sputum samples from 11’212 people were submitted for examination. Upon testing, 2’503 Bacteriologically positive (Bac+) and 2’626 all forms TB patients were identified and put on treatment. The overall smear positivity rate during the intervention has been around 18%.
In the year before the intervention began, RNTCP had enrolled 1’561 Bac+ patients. In the first year of activities, 3’164 Bac+ patients were notified (103% increase). It is important to mention that the overall sputum examination also increased during the intervention. A year before the intervention, the RNTCP tested 10’811 sputum samples, compared to 16’648 in the project’s first year.
With TB REACH Wave 5 Scale Up Funding, the project expanded its focus to 15 treatment units in 4 districts of Maharashtra (Nagpur, Bhandara, Gondia and Chandrapur), where the RNTCP notification rates are below the state and national rates.
Initial results in Maharashtra show increased notification rates for Bac+ patients as well as all forms TB. Compared to Q1 2018, there has been an increase of 40% in Bac+ patients and 90% increase in all forms TB cases in Q1 2019. The project in Maharashtra worked in collaboration with private diagnosis facilities and organized transportation for people to access TB services. However, one of the bottlenecks is limited sample testing by Xpert because of machine scarcity.
Innovative components
Tribal groups face barriers to accessing health care due to long travel distances to reach health facilities and lack of transportation, as well as poverty and poor education which affect health seeking behavior.
The central purpose of the project is to cover the last mile between availability and accessibility by filling in the gaps left by the NTP. For instance, in the town Shivpuri and state of Maharashtra no laboratory technicians were available. In order to make laboratories functional, the project recruited and put in place technicians who were trained by the NTP.
Furthermore, most of the X-Ray machines in the target area were out of order or had no available film, so the project worked in coordination with private X-Ray facilities to provide the necessary supplies and services. The cost or transportation and X-ray services for people with TB symptoms were also covered by the project.
Initially, people with TB symptoms were referred to laboratories for testing; however, it was found that they were unable to reach the facilities by their own means, so a different strategy had to be adopted. A sputum collection and transportation system were put in place and turned out to be a more effective way to get people tested.
The project also devised an incentive-based remuneration system to encourage those who delivered excellent results. The focus was put on incentivizing outcome indicators over process.
Finally, an electronic database management system was implemented to ease the record and analysis of collected data. Thanks to this system, it was possible to conduct operational research to provide nutritional support to patients and investigate the relationship between body mass index (BMI) and treatment outcome.[/vc_column_text][/vc_column][/vc_row]