ACSM Best Practice

1. ACSM Best Practice Country: Dominican Republic Presenter Name: Luis Alberto Rodríguez Reyes Organization: KNCV Date: November 2012

2. History and experience: leading the fight against TB since 1903. Co-founder and co-developer of the standardized and WHO-recommended global TB control method (DOTS) and, through research, many evidence based globally recognized principles. • Over a century’s involvement in Dutch TB control: since its foundation KNCV Tuberculosis • Foundation has played a key coordinating role in TB control in the Netherlands. • Exclusively specialized in TB. • Authority and reputation: one of the leading international players and a respected national and international partner (of WHO, USAID, CIb, donors, technical agencies, and ministries of health etc.) in TB control • Saving lives. • Center for comprehensive expertise and knowledge-sharing on TB control. • Leading a prominent international coalition. • Focus on capacity building of countries. • Local presence. • Global guidelines and policy making. • Strengthening Health Systems. • Comprehensive package: we provide a package approach to TB control, embracing a comprehensive set of measures to strengthen health services and implement TB control programs. • Royal: awarded a royal title in 1953…

3. TB Situation in Your Country* • Prevalence: 45 x 100,000 Hab. (2011) • Incidence: 25 x 100,000 Hab. (2011) • Mortality due to TB: 1.2 x 100,000 Hab. (2010) • TB/HIV co-infection: 18.1 % (2011) • MDR-TB: 120 confirmed cases (2011) Source: National TB Program, Epidemiological Surveillance Unit NTP.

4. Number cases and Incidence of TB BK+ by gender, Dominican Republic, 2011 Source: National TB Program, Epidemiological Surveillance Unit NTP.

5. NTP Goal & Objectives 1* • Goal. Reduce morbidity and mortality due to TB by 50% in relation to 1990 country rates through the strengthening of the NTP based in the Stop TB Strategy. • Objectives. 1. Place TB in the National Political Agenda at the highest level. Source: National Strategic Plan, NTP.

6. NTP Goal & Objectives 2* 2. Expand and improve DOTS services with quality in the National Health System, with emphasis in most at risk groups. 3. Improve health care to TB/HIV coinfected patients. 4. Prevent and control MDR TB. 5. Strengthen the community involvement in the National Response to TB, through the aplication of ACSM strategies. • Integration of most affected communities in TB control activities. • Design and implementation of ACSM strategies to involve CBO. • Activation and Strengthening of Stop TB Committees. 6. Promote research and use the results for the decision making. Source: National Strategic Plan, NTP.

7. TB Control Challenge(s) • Lowdetection of TB suspects. • Majority of the population does not indentifies signs of pumunary TB, cough hygine and cough is socially accepted. • Late diagnose of TB cases. • Stigma and discrimination of TB patients. • Low treatment success rate. • Need to improve capacity building. • Weakness in managerial activities (supervision, M&E). • Limited capacity for data analysis. • Inefficient referral system. Source: National Strategic Plan, NTP.

8. About Your Project Source: National Strategic Plan, NTP.

9. About Your Project 2* Technical Areas: • Universal and early access • ACSM: Community involvement • Infection Control (IC) • Programmatic Management of Drug Resistant TB (PMDT) • Health Systems Strengthening (HSS) • Capacity Building • Supervision • M&E, Operations Research (OR) and surveillance Source: TB CARE I work plan.

10. Whyinvolvethecommunity? • Low case detection in knownhighprevalenceareas. • Needto DELIVER DOTS • Medicationisavailable, butpatients do NOT come togettreatment. • Raiseawareness • Reduce Stigma and Discrimination Increase Case Detection

11. Whatdidwe do in the DR? • Mappingtheneigborhoods: Slums – Gualey (Area IV) • Identifyhighriskgroups: Geographicareas • Poorest of thepoor… • Identifypartners: CBO´s, FBO´s, Private sector, HCP, Communityleaders, etc. • OtherCriteria, communitieswithhighprevalence of: • Violence • HIV • Alcoholism • Poverty • Overcrowding

13. Devlopment of a Plan • ActionOriented • NotRecipes • Layingthegroundwork • Bottoms- up • Kick off meeting: • Sensitization • Epidemilogy • Risksfactors • Groupwork: • Brainstorming • Collaboration COMMUNICATION comes from the Latin word "communicare" meaning to share.

14. Enablingenvironmenttopromoteempowerment… • Providinginformationabouttheriskfactors in theirlocation. • Adaptingthespeechaccordingtothepublic (flexible accordingtotheaudience: women, personsdeprived of theirliberty, drugusers, etc). • Providingexamples of whatthings are possibleto be done: • Showingpictures of activitiesmadebyothercommunities. • “Transferring” theresponsibility of providingguidanceonwhatto do. • Communities define theirpriorities.

15. Whatwouldyou do to Stop TB? • What can be done in yourcommunityto Stop the TB?

16. Conformation of Community Stop TB Committees Group of peoplethat are committed and organized, thathavedeveloped a work plan toimplement Stop TB activities in theircommunitieswiththeir "ownresources”. • Mission: active, early and timelysearch of TB suspects. • Sustain TB awareness and change individual and social behavioraround TB (decreasestigma)

17. baseline data before project started N/A Source: National Strategic Plan NTP + TB CARE I reports. *National goals.

18. ACSM Activities 1 • Conformation of Stop TB Comittees. • Involvement of schools. • Integration of Pharmacies in TB Detection. • Development of photo based strategy: Photovoices. • Raise TB awarness. • Reduce TB related stigma and discrimination. • Sensitization of middle and high level politicians. • TB information Hotline. • Integration of the National Postal Service: “Messengers for Health”. • Involvement of health journalists. • Development of IEC materials for IC.

19. ACSM Activities 2 1. Conformation of Stop TB Comittees: • Community Model (leaded by communty) • Urban and Rural areas • Activities: • IEC activities • Increase TB Suspects detection • Raise Awareness • Hospital Model (leaded by HCW) • Improve quality of services • Provincial Model • Political level • Fund raising??

20. ACSM “Outcomes” • +1,500 members of the Stop TB Committees (community leaders) trained in TB control related topics. • +1,200 HCW trained in the Stop TB Strategy in project selected provinces. • +1,000 HCW sensitized to promote and participate in the activities of the Stop TB Committees.

21. ACSM Outcomes

22. ACSM Outcomes

23. During 2011 training and supervision made possible the implementation of DOTS in all Health Care Services in Monte Plata province. The number of TB Suspects that received lab test (baciloscopy) increased from 77.71% to 90.9%, and the number of TB Cases detected raised from 7 to 24 cases; Eleven cases were detected in six of the newly incorporated health care facilities that also are linked to the Stop TB Committees. In 2012 an increase of 28 sites (34 total) are reporting to the NTP TB Suspects and/or TB Cases.

25. Achievements • MoH Province Directors and NTP local Coordinators empowered, implementing ACSM activities, in project selected provinces. • MoH Province Directors requesting support for the implementation of ACSM activities. • Project was conducting the conformation of committees during first year, by the second year project has focused in capacity building. • Photovoices: “INVISIBLES” Photo exhibit: 8 displays in 4 provinces, including high political institutions (The Congress, MoH, MC, SIUBEN, National Postal Service).

26. Lessons learned • Identification of community leaders facilitates the conformation of the Community Stop TB Committees. • Enable the enviroment to promote empowerment. • Coordinate with the HCW related to the communities in which the Committees operate, guarantees the sustainability of these interventions. • Promote the integration of the authorities such as Provincial MoH Directors, NTP local coordinators, and other Governmental agencies. • Promote the integration of the decision makers, private sector and other “non-health related” organizations. • Community involvement requires that programs and/or projects provide a Comprehensive package: • Provide a package approach to TB control, embracing a comprehensive set of measures to strengthen health services • Enabling an environment in which the community can develop their capacities.

27. Lessons learned • Identification of community leaders facilitates the conformation of the Community Stop TB Committees. • Enable the enviroment to promote empowerment. • Coordinate with the HCW related to the communities in which the Committees operate, guarantees the sustainability of these interventions. • Promote the integration of the authorities such as Provincial MoH Directors, NTP local coordinators, and other Governmental agencies. • Promote the integration of the decision makers, private sector and other “non-health related” organizations. • Community involvement requires that programs and/or projects provide a Comprehensive package: • Provide a package approach to TB control, embracing a comprehensive set of measures to strengthen health services • Enabling an environment in which the community can develop their capacities.

28. Lessons learned • There is evidence of the referrals from the Community Stop TB Committees, however the referral system and the M&E system is weak.

29. THANK YOU FOR YOUR ATTENTION QUESTIONS/COMMENTS???

30. Acknowledgements