M ..Garakhanova,1.S ..Maksud.Makhbubi-Iran,1.S ..Gadzhieva,1.L ..Gougadze2.
1.Azerbaijan.Red.Crescent.Society;.2.International.Federation.of.Red.Cross.and.Red.Crescent.Societies
Consolidated Action Plan, area of intervention 3
69
Azerbaijan |
The Azerbaijan Red Crescent Society became a member of the country TB working group of the NGO constituency.
Important factors for success
An important factor was use of the network of trained NGO staff – nurses, psychologist, social workers – to reach out to patients who would otherwise not have access to DOTS and treatment support. Nurses at TB dispensaries were able to transfer their excess workload to the visiting nurses, who were specially trained to address the needs of long-term DR-TB patients. This improved the quality of care.
Ensuring sustainability
The project was effective and relatively low cost: it improved the quality of treatment and, by supporting adherence, prevented the development of more serious forms of drug resistance. The Red Crescent Society is planning to con-tinue cooperation with international donors and with State structures. It conducts fund-raising and is a sub-recipient of Global Fund grants.
TB patients are still stigmatized, and there are few TB NGOs;
therefore, until now, the country’s Supreme Council, which allocates State grants to NGOs, have not allocated funds for their participation in the TB response. Best practice shows that stigma can be overcome. The success of the project is being used by the recently created NGO coalition to advocate for the interests of TB and DR-TB patients.
Acknowledging the project as best practice will draw the attention of decision-makers and stakeholders responsible for TB control in Azerbaijan to the remaining problems and effective ways to solve them.
Potential for scale-up and future areas of development The Azerbaijan Red Crescent Society has the necessary infrastructure (83 district committees and seven regional centres), the human resources (staff and volunteers, includ-ing in remote areas) and collaboration mechanisms at local and international levels to continue collaboration with State structures to combat TB and DR-TB in Azerbaijan.
70 | Good practices in strengthening health systems for the prevention and care of tuberculosis and drug-resistant tuberculosis
Background
In 2010 in Belarus, M/XDR-TB represented an emergency situation, with a rate of MDR-TB of 32.7% among new cases and 76.6% among previously treated cases and a rate of XDR-TB of 1.7% among new cases and 16.5% among previ-ously treated cases. The proportion of of MDR-TB was con-sistently higher both among new (51.1%) and previously treated cases (100%) in TB/HIV co-infected patients. The MDR-TB treatment success rate was low and mortality dra-matically high. Routine monitoring in 2009–2010 showed that the WHO-recommended treatment regimens were not always correctly prescribed.
In these conditions, the role of the DR-TB consilium was to expedite diagnosis and ensure that individual treatment schemes were correct. The DR-TB consilium is a platform for the input of a broader range of specialists to the discussion of cases in order to find optimal treatment solutions.
Health system challenge
An urgent task of the DR-TB consilium was to train special-ists to participate in multidisciplinary consilia at a decen-tralized level in order to improve the quality of diagnosis and care and to reduce the time to initiation of effective DR-TB treatment throughout the country.
Good practice in health system strengthening to improve prevention and care of M/XDR-TB
The aim of the MDR-TB consilium is to improve MDR-TB treatment outcomes by a multidisciplinary approach to patient management. Although it was initially centralized, the approach was gradually to build capacity in the oblasts to allow decentralized decision-making and to reduce the time to effective treatment initiation.
The MDR-TB consilium has the following functions: registra-tion of new MDR-TB cases, making decisions on treatment initiation, changing treatment regimens, treatment man-agement, transfer of patients to palliative care, evaluation of the severity of side-effects and their management, decid-ing on indications for surgery, managdecid-ing treatment
loss-to-follow-up, cohort analysis and ensuring an uninterrupted supply of TB and supportive medications. The MDR-TB consilium consists of a chairperson, a secretary, specialists in drug management, monitoring and evaluation and labo-ratory work, a radiologist, a surgeon and a TB physician or pulmonologist. Other specialists are sometimes invited (e.g.
a neurologist for a case of central nervous system TB). All MDR-TB cases are reviewed by the consilium before treat-ment initiation and thereafter every 3 months.
The consilium has always been a platform for training dis-trict and provincial specialists. The oblasts provided trans-port for their specialists to attend consilium meetings at least once a month, where the doctors and the heads of oblast consilia presented their cases, accompanied by supporting documentation, and proposed treatment regimens, which were subsequently discussed by the consilium. At least two courses were organized each year for specialists from oblasts and districts, in training facilities well equipped with a nega-toscope and computers for viewing tomograms. The moni-toring and evaluation specialist checked the correctness of patient registration online. At the central consilium meet-ings, the specialists could network regularly in an informal atmosphere, which also improved collaboration.
Outcomes
As knowledge built up at decentralized level and the profes-sionalism of district staff grew, the input required from the central consilium decreased. From 2013, based on recom-mendations of the Green Light Committee, the oblast consi-lia started to work independently, as their training enabled them to make decisions on DR-TB treatment; only more difficult cases were referred to the central level. Initially, central consilia were held for 3 days; they now take only 1.5 days, as they discuss primarily cases in which new drugs, such as bedaquilin and clofazimine, are required. Decisions on treatment with new drugs are taken by a quorum of spe-cialists.
From the start of practice in 2010, consilia at the central and oblast levels have reviewed > 10 000 cases. Largely as
Belarus
DR-TB consilium
A ..Skrahina,.H ..Hurevich,.D ..Vetushko.
Republican.Research.and.Practical.Centre.for.Pulmonology.and.Tuberculosis
Consolidated Action Plan, area of intervention 3
71
Belarus |
a result of these consilia, as noted by Green Light Commit-tee consultants in 2011 and 2013, treatment is prescribed correctly throughout Belarus. According to a countrywide cohort analysis, the treatment success rate increased from 37.2% in 2010 to 54.1% in 2012.
Every TB doctor in the country (at least 100 people) has attended a central consilium and received on-the-job train-ing by presenttrain-ing, analystrain-ing and receivtrain-ing feedback on their cases. In addition, two training seminars were held for oblast consilium members. They can now successfully function as oblast-level consilia. There is one consilium for penitentiaries.
Important factors for success
The MDR-TB consilium was established at the Republican Research and Practical Centre. Its experience was shared,
and oblast representatives received on-the-job training, enabling them to establish similar structures at oblast level.
Now MDR-TB consilia exist in every oblast of the country.
Ensuring sustainability
Consilium activities were initially funded by the Global Fund. In view of their acknowledged usefulness and the motivation of oblasts and districts to continue this prac-tice, the sustainability of the oblast consilia is backed by an order of the Minister of Health, which states that districts must provide transport and per diem for doctors to travel to oblast and central consilia. To maintain their skills, two courses a year will be covered from the NTP budget.
72 | Good practices in strengthening health systems for the prevention and care of tuberculosis and drug-resistant tuberculosis
Background
The TUBIDU project was proposed jointly by various organ-izations in different countries and was led by the Estonian National Institute for Health Development. The project focused on preventing injecting drug use and the HIV-re-lated TB epidemic in participating countries by empower-ing civil society organizations (includempower-ing harm-reduction service providers) and public health professionals. The main targets of the project were people who inject drugs, who are at high risk for HIV infection and TB, especially M/XDR-TB, as they have many social and demographic risk factors that put them in a vulnerable social position (e.g. poverty, unem-ployment, homelessness, imprisonment, malnutrition and limited access to health care).
The TUBIDU project was implemented by seven associates in six European Union countries: the NGO Dose of Love Associ-ation in Bulgaria, the Estonian NAssoci-ational Institute for Health Development (the lead partner) and the Estonian Network of People Living with HIV, the Finnish Lung Health Associa-tion, the Tuberculosis Foundation of Latvia, the Institute of Hygiene in Lithuania and the Romanian NGO Angel Appeal;
and also five collaborating partners in non-European Union countries: World Vision Albania, World Vision Bosnia-Her-zegovina, the National Centre for Tuberculosis and Lung Diseases in Georgia, the Leningrad Region AIDS Centre in the Russian Federation and the International HIV/AIDS Alliance in Ukraine. The project was co-funded by the Con-sumers, Health and Food Executive Agency of the European Commission in the framework of Programme of community action in the field of health (2008–2013).
All the participating countries face the challenges of M/XDR-TB, TB/HIV co-infection and high incidences of TB in vulnerable groups. Six of the countries – Bulgaria, Esto-nia, Latvia, LithuaEsto-nia, the Russian Federation and Ukraine – are high-burden M/XDR-TB countries of the WHO Euro-pean Region.
Health system challenge
Treatment barriers, including poor adherence and limited access to health care, pose challenges to early testing and access to treatment for TB and M/XDR-TB among people who inject drugs.
Good practice in health system strengthening to improve prevention and care of M/XDR-TB
Professionals working in health services and at the policy level (including health specialists in government organiza-tions and NGOs, local municipalities, research instituorganiza-tions and community organizations) have been engaged in efforts to reduce the burden of TB among people who inject drugs and people living with HIV through local and international training, international and country-specific meetings, exchange of good practices during internships, study visits and networking.
Target groups were given intensified training, including study materials and guidelines on TB infection control, case finding and TB/HIV-related health care systems and ser-vices. Guidance was prepared for TB prevention activities in the community by organizations working with people who inject drugs and people living with HIV. Recommendations for policy-makers on future action in the field were prepared and disseminated.
Specific materials were prepared for the project, including guidance documents, handbooks and training outlines for community-based organizations, and policy briefs for pol-icy-makers. These materials were used to raise awareness, provide information, recommendations and guidance for community organizations on inclusion of TB prevention, control and treatment activities in their work with people who inject drugs (including intensified and active TB case finding, contact tracing, informing, educating, counselling and supporting their clients during TB treatment.)