WHO operational guidance on community based TB activities and progress to date

1. WHO operational guidance on community based TB activities and progress to date Haileyesus Getahun Stop TB Department World Health Organisation

2. Outline of presentation • Background and rationale • Objectives, principles and core contents • ENGAGE-TB Approach • Progress in piloting and scale up • Conclusion

3. Problem: delay in diagnosis Time from symptom onset to seeking medical attention 1. Maior et al, 2012; 2. Hinderaker et al 2011; 3. Basnet et al 2009 Why do we need integrated community based TB activities?

4. Problem: Not all identified cases are reported 646 AFB and culture positive cases diagnosed in private laboratories 82 (12.7%) notified to NTP 564 (87.3%) not traced Masjedi et al IJTLD 2007 (Iran) 609 household inhabitants on reported TB treatment 278 (46%) outside of DOTS/RNTCP 331 (54%) DOTS/RNTCP Satyanarayana et al PLoS one 2011 (India) Why do we need integrated community based TB activities?

5. TB can not any more be addressed alone HIV, prison, women, diabetes, alcohol, drug use and smoking Why do we need integrated community based TB activities?

6. Global monitoring of community based TB activities by WHO Key Issues Confusion on what constitute community based TB activities Lack of clarity on what needs to be collected Weak or no indicators Too much qualitative data and difficult to validate Confusion among terminologies and activities (e.g. ACSM) Global TB Control Report • 2006-2009 : haphazard data • 2009-2011 : no data collected

7. WHO Consultation Meeting , October 2010 Strong call for simplified WHO guidance “Like the WHO Interim Policy on TB/HIV” “Despite the fact that the WHO’s Stop TB Strategy was broadened in 2006 to include empowerment of TB patients and their communities, and the WHO produced a document Community Involvement in Tuberculosis Care and Prevention in 2008, there has been lack of clear guidance on how to implement this component of the TB strategy” Statement of CSOs, October 1, 2010

8. Process of development • Builds on existing WHO guidance and documents • Consultations on an earlier draft • Geneva (September 2011) • Lille (November 2011) • Addis Ababa (December 2011) • Writing group meeting (May 2012)

9. Objectives of operational guidance • Define community based TB activities • Simplification and branding • NGOs and other CSOs as key stakeholders • Standardized and measurable indicators • Strengthen one National M and E system by NTP

10. Target audience • Government stakeholders • NTPs and their equivalents • Health stakeholders in other line ministries • Unengaged NGO and other CSOs • Working on health (HIV, MNCH, NCD) • Working on other development areas • Patient and community groups (demand generation) • Donors and research stakeholders

11. Principles • Mutual respect and understanding • Consideration of local context and value • Effective linkage into existing services • One national Monitoring and Evaluation system

12. Core contentDefining community based TB activities • Activities contributing to the prevention, diagnosis, improved treatment adherence and care that positively influence outcomes of all forms of TB. • Carried out by community health workers and community volunteers based on national and local context • Conducted outside the premises of formal health facilities using community based structures and homesteads

13. Core contentDefining community based TB activities • Community health workers • People with formal education • Trained in TB • Role often compensated in kind or cash • Community volunteers • Community members systematically sensitized • Short and specific training scheme • Sessions with professional health workers

14. Examples Community based TB activities • TB awareness creation • Behavior change communication • Community mobilization • Reducing stigma and discrimination • Screening and testing • Sputum collection and transport • TB prevention interventions • Treatment provision and observation • Treatment adherence support • Social and livelihood support • Community led local advocacy activities

15. ENGAGE-TB Approach Six components of simplified operational guidance

16. Priority: Unengaged NGOs and FBOs • International and regional with • Large global or regional coverage • Support to local NGOs or CBOs • Reliable funding sources (e.g. direct marketing- sponsorship, shops) • Work on HIV, MNCH and health but not TB • National • Networks of NGOs and FBOs • Support to CBOs

17. Piloting and scaling up DR Congo, Ethiopia, Kenya, South Africa, Tanzania

18. Key expected outcomes • More unengaged NGOs/CSOs will take up community based TB activities. • Integrated community based TB activities models developed and scaled up (e.g. HIV,MNCH, devt). • Community based TB activities branded, scaled up, sustained and monitored. • TB programme activity performance improved (e.g. case detection, early diagnosis).

19. Progress in piloting and scale up • Project supported by BMSF/STF to develop models for scale up with ENGAGE-TB approach • DR Congo • National consultation carried out • TB in HIV NGOs model – 8 NGOs are readying • Ethiopia • TB into MNCH activities – 2 NGOs engaged • National guidance being developed • Kenya • National consultation conducted • National guidance under development

20. Progress in piloting and scale up • South Africa • National situation analysis undergone in South Africa • Sensitization of NGOs for mainstreaming TB carried out • National consultation to be conducted • Tanzania • Sensitization of NGOs conducted • National guidance being developed • Global • Global operational guidance and branding • WHO NGO Forum being established • Basic indicators agreed and will be mainstreamed

21. Conclusion • NGOs play a critical role to improve TB prevention, care and treatment • The WHO ENGAGE-TB approach provides the framework for enhanced NGO engagement for community based TB activities • Monitoring and evaluation using one national system linked to the NTP is essential