Integrating Network and Community Participation for Effective TB Control in Phayao province, Thailan
The Office of Disease Prevention and Control 10

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Tuberculosis (TB) is infectious disease and most commonly affects the lungs. TB is transmitted from person to person through the expired air from the throat and lungs of patients with active TB disease. The people who expose to TB bacteria can be infected and one-tenth of TB infections will develop TB disease. Globally, there is a new TB-infected person every a second. Fifty percent of TB patients will die unless the treatments are given. Although the Thai government has supported the TB control program and resulting disease seemed to be subsided, the disease has been re-emerged and become national concern after the beginning of HIV epidemic. As the HIV destroys human immune system and have five-time chance to develop TB disease. Moreover, there are the other at risk population, for instance, elderly, prisoners and the household TB contact. TB patients need to daily take anti-TB drugs for at least six months. Some drugs produce a variety of side effects, for instance, rash, nausea, stomach ache, vertigo, or even life-threatening reactions. The terrible suffering events result in no longer taking their medications, and consequently drug-resistance TB could be developed and the TB bacteria are able to spread to the others. In 2013, Thailand was ranked in the twenty-two high TB-burden countries. WHO estimated that there were 80,000 new TB cases, while only 60,000 cases were reported. Therefore, 20,000 cases have not been diagnosed and treated, and they can continually spread the disease in their communities. The Office of Disease Prevention and Control 10th (DPC10) is responsible for disease control in eight provinces in upper North of Thailand where has been the area of high HIV prevalence. The prevalence of TB with HIV co-infection patient increase from 36 ,39 and 41 in orderly from 1997 to 1999. Phayao is a province in DPC10 responsible area and connects to Lao PDR. Phayao has been ranked the top five province of the highest HIV prevalence in Thailand. In 2005, there were 876 registered TB patients and 28 percents were TB with HIV co-infections. The success rate of TB treatment was 67.5 percents, death rate was 18.8 percents and the rate of default on treatment was 3 percents. In 1993 TB infected rate was 4,184 per hundred thousand population among prisoners compared with 119 in normal Thai population. Between 2005 and 2010, multiple drug resistance TB patients were reported 16 cases and therefore the cost of individual treatment were approximately 129 times higher than ordinary regimen. In the past, tuberculosis control focused on only treatment in hospitals. There was no proactive screening for early case detection in communities. In addition, health personnel needed to allocate their time for manually TB records and report to national level. Therefore, they had inadequate time to effectively care the patients and monitoring the patients’ drug adherence. There was no the system that can communicate among hospitals and communities for good quality and patient safety care. In addition, people in communities need more knowledge and awareness of TB disease.

B. Strategic Approach

 2. What was the solution?
Office of Disease Prevention and Control 10th (DPC10) under Ministry of Public Health (MOPH) is a regional academic agency which is responsible for eight provinces in the upper north of Thailand including Phayao province. Our mission is mainly respond to disease surveillance, prevention and control through the health policy, partnerships and networks, information technology and research. According to the aforementioned problems, our organization (DPC10) decided to initiate this project. Our primarily aim of the project focuses on TB prevention and control. We have tried to improve the cure rate, decrease the mortality rate, and decrease the drop-off rate or discontinuation to treatment rate. The continuation to treatment effect the decrease the chance of the disease transmission to families and community and the chance of developing multi-resistant of TB treatment (Treatment as Prevention). Moreover case detection and community awareness is main objectives. Our key targets were TB clinic in all level of hospitals and networks in the communities. The multi-partners worked together for solving the TB problems. The strategies for dealing with the problem were: 1) To develop an effective TB information technology system We have developed the TB Information Technology System that contains update information about TB situation including disease detection, prevention, control and treatment. Also we have standardized and updated our database annually. We have used a PDCA (Plan-Do-Check-Act) process to help responsible providers analyzing the TB data for service arrangement and finding solutions in these groups such as TB patients with HIV, children who live with TB patients, MDR TB. 2) To promote collaboration from network and community We collaborated with provincial public health office, District public health office, general hospital, District hospital, Sub-district health promoting hospital, detention center, department of local administration, village health volunteers and village headers. All participants can use their own analyzed data from the TB IT system that make them realized about their own problems and planed their local strategies with sharing local community recourses hope for effective driving of the integration of TB program and referral system. 3) To develop a human resource Capacity building were give to TB local Health officers team of hospital consist of multidisciplinary teams including physicians, nurses, public health officers, pharmacists and laboratory technicians have be trained to manage, analyze, and apply the information from the TB records. Also we provided the knowledge and shared experience about TB disease and management according to Thai National Tuberculosis Program (Thai NTP). These activates aimed to increase the number of operation health officers with essential performance for dealing with TB problem in their communities. Community team consist of nurses in prisons ,prisoner health leaders ,village health volunteers and communities’ leaders were be trained about community detection and observation about medicine adverse effect.

 3. How did the initiative solve the problem and improve people’s lives?
We (DPC10) developed the TB Information Technology System. This system can alert the providers when it detects abnormality events, for example the TB patients do not come to receive their treatments. The community centers can use the analyzed data for service arrangements, high risk surveillance, treatment planning, patients’ referral system, and follow-up program for patients and contacted people. The TB Information Technology System connects all database of community services together. This makes our connections seeing common problems that have happened. This improves the coordination between the network. In addition, this system that has established in TB services encouraged the cooperation from the local governments and communities which leads to the co-operative community model. This “model” initiated to emphasize on including involving people from the community to be part of the problem solving processes.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
This project was first conducted in 2005 at Sankampang hospital, Chiangmai. This hospital is an District hospital that has 30 beds. They created a database for TB patients to resolve the problem of patients’ data loss and the manual report keeping. We (DPC10) have supported our health networks in terms of TB surveillance and preventions. We have extended the capacity of the original Sankampang database to the TB information system that can help for disease detection, prevention, control and treatment. We have developed our TB database every year by expanding our connection with hospitals. During the development process, we listen to our connections’ needs and feedback while trying to improve our system according to their needs. This process is repeated until we and our connections are agreeable. We call this process as Plan – Do – Check – Act. The TB information system contains four components including 1) common TB patients, 2) MDR-TB patients, 3) Household contacts, and 4) TB laboratory. Our system has been easy to use and even if untrained officers who has a little computer background can use it. We have continually developed our TB information system for helping a local officer about TB report. Each setting which can access to this database can use this data for tracing and referring TB patients. In addition, the information in the database can be used for statistics analysis and reports in terms of remission rate, mortality rate, treatment discontinuation rate (default rate), treatment quality, the newly diagnosed patient rate, and screening for high risk patient. The second strategy: cooperative connection development Because of smart database ,health networks can use analyzed the data to explore their own problem and realise to cope the problem .We arranged a number of meetings with our connections for brainstorming creation of the treatment plan, referral plan, and follow-up plan for TB patients in local level. We monitored our health networks, gave them suggestions, and set meetings with them in order to improve our new guideline for taking care of TB patients. We have a guideline for screening TB in HIV patients, a guideline for taking care of prisoners with TB, a guideline for screening household contact, and a guideline for surveillance MDR TB patients. The third strategy: human resource development We did gap analysis and need assessment, and found that our officers and health networks needed more knowledge and skills in TB disease. Then, we developed a training program for healthcare providers, screws, and volunteers in a community. The training programs that we developed are for both new providers and experienced providers. The examples of program are the curriculum for administrating a TB clinic ,the program for TB care for new providers, the Directly Observed Treatment (DOT) watcher program, the program for TB screening in the community for volunteers.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Model development “Integrating Network and Community Participation for Effective TB Control in Phayao province” was an example of Community base Participation that encourage the change in TB policy from community level and also continuation for sustained the TB problem solving of the community. In this community program, we have various stakeholders that hold different responsibilities as follows: • Public hospitals, private hospitals, and detention centers are responsible for TB diagnosis and treatment. These settings are required to transfer patients’ information to patients’ local clinics. • Sub-district health promoting centers are helping community connections and village volunteers in terms of TB screening, and referral process. In addition these centers are responsible for tracking patients’medication, observing drug allergy symptoms, and visiting patients at thier homes. • Phayao provincical public health center is reponsible for supporting district public health centers • DPC10 is responsible for providing knowledge about TB, follow up, and evaluating the process. In addition, DPC 10 compiles and reports the data, received from the community, to the policy maker, and trains officers who involve with TB clinic.
 6. How was the strategy implemented and what resources were mobilized?
Significant resources in supporting the operations in order to achieve the goal in controlling Tuberculosis (TB) had very important components which were personnel, budget, equipment, and medical supplies. For human resources, the most important were the health officers of the Office of Disease Prevention and control, region 10th (DPC10) consisting of doctors, nurses, pharmacists, laboratory technicians, public health officers. For Health officers in Phayao Province level, it consisted of provincial TB coordinator (at least 1 district TB coordinator per one district) and District Hospital personnel that consists of doctors, nurses, pharmacists, laboratory technicians, and hospital TB coordinator. For prison section, it consisted of prison commanders, prisoner TB leaders ,doctors, and nurses from the nursing service inside the penitentiary. For local administrative section, it consisted of administrators, officers from the public health of the local administration. For public sectors, it consisted of mainstay in village health volunteers that 1 person took care of 10-15 households and communities’ leaders. For the budget, the DPC10 had allocated the budget to support the development of operation format, to train new staff, to provide curriculum for development of the operation on the integration of TB and other related diseases, to monitor the implementation of the program, to make a standard assessment on the tuberculosis clinic operation, and set the meetings to present the activities, outputs and outcomes of the program in the regional area (the 8 provinces in the upper North of Thailand) including the supporting on the allocation budget and improving the TB database until it could be standardized. Some budget came from local administration for TB screening and public relation about TB knowledge and awareness in the community. For materials, equipment and medical supplies, there were supports for recording program, operation manuals, guidelines for operation of tuberculosis control, anti-tuberculosis drugs for hospitals where providing their service to patients who have no or lack of treatment access, and medical equipments such as gloves, safety mask, sputum cartridge, agar. There was also a support for tuberculosis diagnosis confirmation and drug susceptible testing through TB laboratory by using special techniques.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The output in developing TB Information technology System was the database which covered the 4 areas of information. They are (1) general TB patient, including TB-HIV co-infected patients, (2) the household TB contact, (3) Multi-drug resistant TB (MDR-TB) patients and (4) TB laboratory diagnosis. Local health officers could analyzed the data and then make their suitable local TB management plan between village health volunteers and Sub-district health promoting hospital. The system also has an alert function as it can inform the health care provider about the patients who were lost to continuously receiving treatments, or migration. The system also has information that shares and connects among the hospitals where patients could be referred for treatment. The information is also used for the evaluation and plan for timely management of the TB problems. For the network output, there were the joining networks from 18 areas consisting of Provincial Public Health offices, District Health Offices, Provincial Hospitals, District Hospitals, Prisons and leaders of civil society. The results showed the development on the integration mechanism and consequently made the appropriate action plan for the local contexts. Therefore, there was the occurrence of the working process that initiated from the problem-based learning, and resulted in the development of their local operational guidelines that suit with the local contexts. For example, the management guideline for TB and HIV co-infection, the guideline for management of TB in the prison, the guideline for diagnosis and treatment for the household contacts under 18 years old, and the guideline for MDR-TB surveillance via cooperation with health networks. For the output in personnel development and services in the TB clinics, there were people who passed the various capacity building training courses such as TB diagnosis and treatment for Internists, TB microscopic diagnosis, comprehensive TB control program for new TB clinic officers, treatment and care for the TB household contacts, MDR-TB case finding and diagnosis, and the utility of the records in the database that accounted for 257 trainees. The program focused on developing local health personnel for increasing their performance in TB prevention and control. The trainees were consisted of doctors, nurses, pharmacists, and laboratory technician. After training, they could be able to practice in accordance with Thai National Tuberculosis Program in terms of case finding, diagnosis, treatment, and transferring knowledge and experience to village's health volunteers for screening people with suspicious symptoms, home visiting, and directly observed treatment.

 8. What were the most successful outputs and why was the initiative effective?
This TB control model development which has cooperatively run among health networks and communities and it started the operation since 2009-2011. This system was initiated with the problem-based learning, solving the problems, and development the model until it was the good practice. The model was shared to the public and it was consciously developed with the match for the local contexts. It has been evaluated and developed continuously since 2012 onwards. TB information technology system emphasized on monitoring the quality of the records and the data flow in order to assess the validity from Phayao Provincial Public Health office and the DPC10. The system has been used to check the accuracy and completeness of the recorded data, for providing the high quality information. We (DPC10) have requested the area to submit the information to us. The evaluation process was divided into three phases. The first phase, the timeliness of data submission was evaluated in every 30 days. The second phase, the validity of the patients’ registration record was assessed in every 90 days, and the Third phase, the quality and validity of the data were annually examined. The evaluation of TB control program in each local area used the key indicator which was the success rate of treatment in new registered TB patients should be exceed 85 percent at the baseline and annually increase at least 2 percent in success rate according to the World Health Organization (WHO) target. To achieve this goal, the death rate and default of treatment rate must be minimized. The quality evaluation of TB service in each hospital was composed of two steps. The first step was the hospital self-assessments via the standard evaluation form. The second step, the DPC10 officers randomly selected the hospitals for quality assessment with careful consideration. The DPC10 officers examined the treatment outcomes of TB patients, case findings and cooperation with health care networks. In 2013, all TB clinics in Phayao province were passed the criteria of the standard evaluation.

 9. What were the main obstacles encountered and how were they overcome?
1. The technology problem: Originally, there was a variety of TB information systems in terms of Hardware and Software. Therefore, the system was needed to be updated frequently, and the local users felt unhappy with this situation. DPC10 personnel have tried to help the users for updating the program in the local area at least once a year. DPC10 also have offered channels for consultation, for example, Facebook® and mobile phone which was able to directly contact with the programmers and the model development team in anytime. 2. The personnel problems: There was a high turnover rate of TB coordinating persons resulted in discontinuous TB work in the local area. To fill this gap, DPC10 surveyed for the new TB staffs and created the training for them. There were some refresher courses for experienced officers. DPC10 also offered knowledge and technical support to health networks via clarification of the guideline on TB control program, supervision, monitoring and consultation. 3. The problem related to implementation of the network in the area: The civilian societies in the local area thought that TB was not a public health concern. They did not understand the TB natural history and the importance that the societies should support TB patients to completely and regularly take anti-TB drugs for prevention of the MDR-TB. Therefore, the local communities were not interested in TB prevention and control. However, the problem was solved by providing knowledge of TB natural history and the mode of TB transmission. In addition, the smart database which has been available in every local area would make the communities paying their attention and preferable cooperation the implementation because they knew their local TB situation; they would explore the potential causes of TB problems and find the reasonable way to solve the problems.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
This initiative made the model of effective service in TB clinics. TB clinic officers were trained and had confidence in providing services for TB patients. They were also able to operate their works according to TB clinic standard with patient-centered scheme. The initiative also created the developed operational guidelines from knowledge management process among the health networks, for instance the fast track service and one stop service for TB patient. According to the randomly evaluated the quality of TB clinic by DPC10 in 2013, all TB clinics in Phayao province were passed the criteria of the standard evaluation. It made the cooperation among health networks in terms of monitoring and preventing the TB transmission by providing Directly Observe Treatment (DOT) for every patient. Therefore, patients were willing to adhere TB treatment. Once the drug allergy effect was observed, the doctors would adjust the proper regimen or quit taking the highly suspected allergic drugs. Consequently, it could prevent the death caused by severe drug adverse reactions. In addition, TB patients’ home visit via multidisciplinary team of the hospitals, sub-district Health Promotion Hospitals, and Village health volunteers were beneficial for the patients because they not only examined the clinical status but also evaluated the surrounding environment, provided suggestion for infection control. Some information from home visit was sent to the local administrative organization to support underprivileged patients. Moreover, the initiative would facilitate health personnel to perform TB screening in at risk population such as elderly, HIV positive population, other patients with chronic diseases, and household contacts. Such operation could reduce the death rate during the treatment as TB patients were able to access the service at the early stage. The improvement of the outcome of the project was shown that in 2005, there were 67 percent of the treatment success rate, 18.8 percent of death rate, and 3 percent of default of treatment rate. In 2013, the percentage of treatment success rate increased to 77 percent, the death rate reduced to 13.8 percent, and the default rate reduced to only 1 percent. For TB with HIV coincidence patients, in 2005, there were 52.6 percent of the treatment success rate, 34.7 percent of the death rate, and 2.1 percent of default rate. In 2013, the percentage of treatment success increased to 68 percent and the death rate reduced to 11.5 percent, and the default rate reduced to only 1 percent. In addition, the patients who underwent completely treatment would be prevented the occurrence of MDR-TB. From 2005-2012, there were 16 MDR-TB patients, but no MDR-TB were found in 2013. In 2012, the TB screening system was launched in Phayao. There were 3 prisoners who were registered for TB treatment in 2012 and 7 prisoners were diagnosed as TB in 2013. TB infected rate in prisons was decrease from 4,184 per hundred thousand population in 1993 to 471 in 2003. The TB database was used in (1) community and civilian sectors to analyze the data and develop the action plan for local population health between village health volunteers and Sub-District Health Promotion Hospital in order to ask for the budget support for the operation from the local administrative organization. (2) For hospital sector, the data could be analyzed for the evaluation of the TB service, including the monitoring of patients’ treatment and referral system for the migration of TB patients. The utility of the information included the budget allocation for the TB operation and medical supplies from National Health Security Office in provincial level, regional level, and Bureau of Tuberculosis. The key objective in this level was to exchange the information and use it as a benefit tools for the development of TB services. The system made the TB stakeholders having the information and they readily developed the TB service from every year to every 6 months and promising monthly meeting for the development of TB services in 2015. (3) For the National Health Security Office level, the data was brought for the TB program management, budget allocation, and the medical supplies in each TB clinic. The information has improved the quality of TB treatment, reduced expired medications, and decreased the insufficient medication supplies for TB patients in the hospitals.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The office of Disease Prevention and control region 10th (DPC10) had developed the initiative that was the TB control model development which has cooperatively run among health networks and communities. The model was also jointly developed and operated with local context concern. In addition, the creation and development of TB information technology system has been the key tools for the implementation of this program. The implementation of the model including the TB IT system was continuously extended in all 8 provinces in the upper North of Thailand. This was the example of the initiation of local problem-based operation via cooperation among local health networks. The Bureau of Tuberculosis, Thailand has appreciated the model and extended the implementation in all over the country. Nowadays, the model is accepted and included in the National policy and therefore, it will benefit the TB control program and possibly other countries in the long run. The sustainability of the model has been existed because the relevant TB networks have shared the information in the single database. The information has utilized and solved the local TB problem with cooperation among local health networks. The jointly operation among DPC10 and all health networks in this region (the 8 provinces in the upper North of Thailand) could build the feeling of ownership and see the common strength, weakness, opportunity and threat. Therefore, the continuous development of the model has been willing to jointly perform. Knowledge management have been also the important tools for develop the knowledge and innovation for TB control, including the knowledge dissemination from experienced personnel to new staffs. In addition, this cooperative TB control program could be applied to manage other problems of chronic diseases.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The implementation of this TB control model development which has cooperatively run among health networks and communities in Phayao province began with problem-based approach and the common desire for solving TB problems. This implementation has been existed because the jointly operation in all level of health networks and all TB health care providers sacrifice their time and manner for service-minded caring TB patients until they were cured. The family and community participation on health promotion and care has caused the rapid and convenience access to TB services and other basic medical needs for local people in communities. Moreover, TB control in families and communities has been more effective. The population or patient-centered method has directly provided a good impact to the population as it has responded to their requirements. The public, private and population participation have reduced the conflict with officials, facilitated the TB concern among people and communities, and improved the quality of TB services. This participation model has increased the success rate of TB treatment and reduced the default rate of TB treatment. According to our works, we can summarize the lesson learned as follows: 1. To develop the TB information technology system: this was the TB health networks requirement for resolving TB problems in the area. Before implementation of the model, the problems were the workloads of manual TB record and report and the lack of evidence for dealing with TB problem in their local responsible areas. 2. To develop the appropriate roles: this was the process of human resource development in a variety of methods. For instance, we trained TB health personnel to able to practice according to Thai National TB control program. Coaching and mentoring including budget support were also applied. Therefore, the trainees (health care providers) would have the knowledge and creative thinking for development of TB control in their responsible area. 3. To build the strong relationship network: this has built the ownership of TB control program via a number of methods. For instance, the validity, completeness and timeliness information that has affected directly to community members would be disseminated and clearly answered any inquires from communities. The TB problem solving, including TB infection control would be common desire for communities. Suggestion for the development 1. The teamwork of the health networks requires the continuous perform of knowledge management in order to knowledge sharing among members in the communities of practices. They are able to substitute their works in the absent of their colleagues. The TB knowledge transfers and the teamwork cause the confidence and trust among the teams and population, and they are willing to jointly perform the TB control activities. 2. To support our global region (the South East Asian countries) due to the coming of ASEAN economic community, the model of resource sharing and cooperation in public service will be more essential in the near future as the massive of demand and limit on resources. This model can be applied to deal with other health problems that need multidisciplinary participations.

Contact Information

Institution Name:   The Office of Disease Prevention and Control 10
Institution Type:   Government Agency  
Contact Person:   Dr.Wittaya Liewsaree
Title:   Director Office of Diseases Prevention Control  
Telephone/ Fax:   66 53 140 767
Institution's / Project's Website:  
E-mail:   sao2334@gmail.com  
Address:   447 Chiangmai-Lumphum Rd., T. Watkate, A.Muang
Postal Code:   50000
City:   Chiang Mai
State/Province:   Chiang Mai
Country:  

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