International non-governmental organizations’provision of communitybased tuberculosis care for hard-to-reach populations in Myanmar,2013-2014

Background:National tuberculosis(TB)programs increasingly engage with international non-governmental organizations(INGOs),especially to provide TB care in complex settings where community involvement might be required.In Myanmar,however,there is limited data on how such INGO community-based programs are organized and how effective they are.In this study,we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar,and assess their contribution to TB case detection.Methods:We conducted a descriptive study using program data from four INGOs and the National TB Program(NTP)in 2013-2014.For each INGO,we extracted information on its approach and key activities,the number of presumptive TB cases referred and undergoing TB testing,and the number of patients diagnosed with TB and their treatment outcomes.The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.Results:All four INGOs implemented community-based TB care in challenging contexts,targeting migrants,post-conflict areas,the urban poor,and other vulnerable populations.Two recruited community volunteers via existing community health volunteers or health structures,one via existing community leaderships,and one directly involved TB infected/affected individuals.Two INGOs compensated volunteers via performance-based financing,and two provided financial and in-kind initiatives.All relied on NTP laboratories for diagnosis and TB drugs,but provided direct observation treatment support and treatment follow-up.A total of 21995 presumptive TB cases were referred for TB diagnosis,with 7383(34%)new TB cases diagnosed and almost all(98%)successfully treated.The four INGOs contributed to the detection of,on average,36%(7383/20663)of the total new TB cases in their respective townships(range:15-52%).Conclusion:Community-based TB care supported by INGOs successfully achieved TB case detection in hard-toreach and vulnerable populations.This is vital to achieving the World Health Organization End TB Strategy targets.Strategies to ensure sustainability of the programs should be explored,including the need for longer-term commitment of INGOs.

The contribution of a non-governmental organisation’s Community Based Tuberculosis Care Programme to case finding in Myanmar:trend over time

Background:It is estimated that the standard,passive case finding(PCF)strategy for detecting cases of tuberculosis(TB)in Myanmar has not been successful:26%of cases are missing.Therefore,alternative strategies,such as active case finding(ACF)by community volunteers,have been initiated since 2011.This study aimed to assess the contribution of a Community Based TB Care Programme(CBTC)by local non-government organizations(NGOs)to TB case finding in Myanmar over 4 years.Methods:This was a descriptive study using routine,monitoring data.Original data from the NGOs were sent to a central registry within the National TB Programme and data for this study were extracted from that database.Data from all 84 project townships in five regions and three states in Myanmar were used.The project was launched in 2011.Results:Over time,the number of presumptive TB cases that were referred decreased,except in the Yangon Region,although in some areas,the numbers fluctuated.At the same time,there was a trend for the proportion of cases treated,compared to those referred,that decreased over time(P=0.051).Overall,among 84 townships,the contribution of CBTC to total case detection deceased from 6%to 4%over time(P<0.001).Conclusions:Contrary to expectations and evidence from previous studies in other countries,a concerning reduction in TB case finding by local NGO volunteer networks in several areas in Myanmar was recorded over 4 years.This suggests that measures to support the volunteer network and improve its performance are needed.They may include discussion with local NGOs human resources personnel,incentives for the volunteers,closer supervision of volunteers and improved monitoring and evaluation tools.

Engagement of public and private medical facilities in tuberculosis care in Myanmar:contributions and trends over an eight-year period

Background:As part of the WHO End TB strategy,national tuberculosis(TB)programs increasingly aim to engage all private and public TB care providers.Engagement of communities,civil society organizations and public and private care provider is the second pillar of the End TB strategy.In Myanmar,this entails the public-public and public-private mix(PPM)approach.The public-public mix refers to public hospital TB services,with reporting to the national TB program(NTP).The public-private mix refers to private general practitioners providing TB services including TB diagnosis,treatment and reporting to NTP.The aim of this study was to assess whether PPM activities can be scaled-up nationally and can be sustained over time.Methods:Using 2007-2014 aggregated program data,we collected information from NTP and non-NTP actors on 1)the number of TB cases detected and their relative contribution to the national case load;2)the type of TB cases detected;3)their treatment outcomes.Results:The total number of TB cases detected per year nationally increased from 133,547 in 2007 to 142,587 in 2014.The contribution of private practitioners increased from 11%in 2007 to 18%in 2014,and from 1.8%to 4.6%for public hospitals.The NTP contribution decreased from 87%in 2007 to 77%in 2014.A similar pattern was seen in the number of new smear(+)TB cases(31%of all TB cases)and retreatment cases,which represented 7.8%of all TB cases.For new smear(+)TB cases,adverse outcomes were more common in public hospitals,with more patients dying,lost to follow up or not having their treatment outcome evaluated.Patients treated by private practitioners were more frequently lost to follow up(8%).Adverse treatment outcomes in retreatment cases were particularly common(59%)in public hospitals for various reasons,predominantly due to patients dying(26%)or not being evaluated(10%).In private clinics,treatment failure tended to be more common(8%).Conclusions:The contribution of non-NTP actors to TB detection at the national level increased over time,with the largest contribution by private practitioners involved in PPM.Treatment outcomes were fair.Our findings confirm the role of PPM in national TB programs.To achieve the End TB targets,further expansion of PPM to engage all public and private medical facilities should be targeted.

Different challenges,different approaches and related expenditures of communitybased tuberculosis activities by international non-governmental organizations in Myanmar

Background:International non-governmental organizations(INGOs)have been implementing community-based tuberculosis(TB)care(CBTBC)in Myanmar since 2011.Although the National TB Programme(NTP)ultimately plans to take over CBTBC,there have been no evaluations of the models of care or of the costs of providing CBTBC in Myanmar by INGOs.Methods:This was a descriptive study using routinely-collected programmatic and financial data from four INGOs during 2013 and 2014,adjusted for inflation.Data analysis was performed from the provider perspective.Costs for sputum examination were not included as it was provided free of charge by NTP.We calculated the average cost per year of each programme and cost per patient completing treatment.Results:Four INGOs assisted the NTP by providing CBTBC in areas where access to TB services was challenging.Each INGO faced different issues in their contexts and responded with a diversity of strategies.The total costs ranged from US$140754 to US$550221 during the study period.The cost per patient completing treatment ranged from US$215 to US$1076 for new cases and US$354 to US$1215 for retreatment cases,depending on the targeted area and the package of services offered.One INGO appeared less costly,more sustainable and patient oriented than others.Conclusions:This study revealed a wide variety of models of care and associated costs for implementing CBTBC in diverse and challenging populations and contexts in Myanmar.Consequently,we recommend a more comprehensive evaluation,including development of a cost model,to estimate the costs of scaling up CBTBC country-wide,and cost-effectiveness studies,to best inform the NTP as it prepares to takeover CBTBC activities from INGOs.While awaiting evidence from these studies,model of CBTBC that have higher sustainability potential and allocate more resources to patient-centered care should be given priority support.

Active case-finding for tuberculosis by mobile teams in Myanmar:yield and treatment outcomes

Background:Since 2005,the Myanmar National Tuberculosis Programme(NTP)has been implementing active case finding(ACF)activities involving mobile teams in hard-to-reach areas.This study revealed the contribution of mobile team activities to total tuberculosis(TB)case detection,characteristics of TB patients detected by mobile teams and their treatment outcomes.Methods:This was a descriptive study using routine programme data between October 2014 and December 2014.Mobile team activities were a one-stop service and included portable digital chest radiography(CXR)and microscopy of two sputum samples.The algorithm of the case detection included screening patients by symptoms,then by CXR followed by sputum microscopy for confirmation.Diagnosed patients were started on treatment and followed until a final outcome was ascertained.Results:A total of 9349 people with symptoms suggestive of TB were screened by CXR,with an uptake of 96.6%.Of those who were meant to undergo sputum smear microscopy,51.4%had sputum examinations.Finally,504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%.Among total cases examined by microscopy,6.4%were sputum smear positive TB.Treatment success rate was high as 91.8%in study townships compared to national rate 85%(2014 cohort).Conclusions:This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts,especially when equipped with portable,digital CXR machines that provided immediate results.However,the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis.In order to optimize the ACF through mobile team activity,future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.