ENGAGING THE COMMUNITY IN SUSTAINING QUALITY IMPROVEMENT INITIATIVES IN TB/HIV CARE | RCQHC

Across the planet, TB kills some 1.4 million people, making it the world's second deadliest infectious disease after HIV/Aids. While deaths from TB remain high in Africa, the continent is on track in terms of the MDG target to reduce the number of new infections and there is hope that Africa will make faster progress against the disease with the scale up of TB/HIV care and active community involvement among other initiatives.

The TB collaborative through a series of Regional Center for Quality of Health Care (RCQHC) suported quality improvement processes observed unsatisfactory TB/HIV care performance indicators attributed to among other factors the low levels of community involvement in TB/HIV care in East Africa. To remedy this, in December 2010 RCQHC set out to suport the introduction of a Primary Health Care/Commumity Collaborative in Tanzania in the three districts of Iringa, Kilolo and Mbinga. Prior to the intervention the community was only partially involved through community health workers (CHW) whose egagement was limited to service delivery and not planning, decision making or finacing.

The PHC/community engagement model was developed and has been implemented from December 2010 in Tanzania. As a result of the model, there has been a marked increase in community involvement with a diverse representation of the community taking part in the planning, implentation, resource mobilization and decision making regarding TB/HIV care services. Stakeholders include District Executive Directors, ex TB patients, local government politicians, health workers, district planners, community development officers, NGO representatives/development partners e.g (CUAMM). Quality improvement teams at district, ward and village levels were formed to steer the QI initiatives and ultimately improve TB/HIV care. Activities planned and being implemented include; screening PLHAs for TB, intergeration of TB screening in the reproductive health, childhood care, PMTCT, antenatal and post natal care clinics, tracing contacts of smear positive TB cases using CHW and ex TB patients, raising awareness in the community and renovation of laboratories. Worth noting is the fact that the activities in the workplan were funded by the districtsÔÇÖ comprehensive health plans (Mbinga USD1827, Iringa USD 1480, Kilolo USD 1706). In iringa the community health funda contributed USD 380 and CUAMM USD 760 in Iringa. Monitoring and review of progress of activities was jointly done by the QI and PHC teams. District QI teams participated in regional learning sessions biannually to share lessons learnt and adapt promising/ innovative practices from the collaborative.

As a result of these activities, 105 out of 666 HIV positive mothers in Iringa were screened for TB and 100 out of 589 in Kilolo district. Between February and December 2011, 3 mothers from iringa and Kilolo were found to have TB and treated. The number of TB cases found in the three districts increased from 1066 to 1253 from 2010 to 2011 while the proportion of TB patients tested for HIV and TB HIV coinfected patients on septrin prophylaxis therapy increased from 86.9% to 92.8% and 91% to 94% respectively.

Inspired by the success of the TB PHC/community collaborative in Tanzania, Kenya decided to join the the PHC /community QI Collaborative in February 2012. The District TB Leprosy Coordinator (DTLC) of Makueni district in Kenya spearheaded the replication of the model in the district. Supported by an NGO; Kenya Episcopal Conference, The DTLC organized a meeting with the District Health StakeholderÔÇÖs Forum (DHSF) in March 2012 to introduce quality improvement in TB health service delivery. The meeting attracted 30 stakeholders included; private clinics and pharmacies, international agencies (AMREF, World vision, ICAP), CBOs including: Wote Youth Development Project (WYDP), Christian Health Association of Kenya (CHAK), Kenya AIDS National Consortium Organization (KANCO), TB Action Group and district health personnel, prison in charge, Ex TB support groups, Makueni town council memebers, chairman for the disabled and a prominent supermarket proprietor. A TB quality improvement team for Makueni District comprising of 10 members from the stakeholderÔÇÖs forum was formed with a mandate to steer Quality improvement in TB prevention and control in the district.

Since March, WYDP has supported the training of 60 CHWs, TB Action Group the training of 2 community units (Mumbuni and Nziu CUs), KANCO the re-training of 30 CHWs in the district and the formation of Makueni Ex-TB patient support group. CHAK also supported meetings of stakeholders on ICF and sensitization meetings for community CB-DOT. KEC supported TB Active case finding meetings for stakeholders and the sensitization and training of 2 community units on CB-DOTs.
As observed with the collaborative in East Africa, employing the PHC/community collaborative model can go a long way in improving TB/HIV care.