Questions/Answers

Tuberculosis (TB) has been prevalent in prisons due to prisoner characteristics with risk factors of TB and overcrowding prison with limited ventilation. As TB is preventable, treatable and curable, no one, including prisoners, should suffer from TB. Prisoners have rights to access quality health care services as general population does. Regarding Sustainable Development Goals (SDGs), initiatives have been implemented in prisons in Thailand to end TB among this high-risk population. The objectives of the initiative are: (1) to establish Quality Assurance (QA) of TB services in prisons to ensure all prisoners have inclusive and equitable access to the quality TB services; (2) to strengthen capability of prison authorities and local health authorities to make decision to support quality TB services in prisons; (3) to empower volunteer peer educators to identify early-stage TB found in the prisoners which promotes equality of access to health care services; (4) to apply available resources to support top quality of TB services in prisons; and (5) to achieve equal opportunity of outcomes of care through notification rate, treatment success rate, and percentage of anti-retroviral therapy (ART) for TB patients with HIV infection and treatment success rate so that the epidemic of TB in prisons ends.

Quality Assurance of TB services in prisons is directly linked to Category 1. This helps ensure that all prisoners have access to quality TB services in accordance with the national guidelines. Not only does it aim at integrating processes, minimising delays, providing official feedback, disseminating online results to the public, and improving ownership, but also develops a formal system to measure quality of TB services in prisons. Its concrete results, which determine differences between quality indicators and actual results, can guide all stakeholders to sustain strengths and rectify weaknesses so that progress towards the SDGs can be made.

national efforts to end TB have been focused on achieving targets of the SDGs. First, results of the quality assurance contribute to SDG 1.3, SDG 3.8, and SDG 10.3. Second, its process of providing feedback to officials who are decision makers at all levels, generating TB data disaggregated by prisons available online for the public, and empower volunteer peer educators further contributes to SDG 16.7, SDG 16.10, and SDG 10.2, respectively. Last, the impact of quality services, which help patients to be cured from the disease and prevent others from TB infection, support the achievement of SDG 3.3.

Quality assurance about TB services in prisons contributes to safeguard life and quality of life of the prisoners. First, any delay in TB diagnosis frequently happens in prisons, and it can harm both patients with disease severity and communities with TB transmission. Quality indicator 1-5 measures the activities of screening and diagnosis such as number of prisoners annually screened for TB. If prisons do not achieve these desirable results, local health authorities and prison authorities will assist prisons to change their shortfalls. Second, improper treatment and care have adverse effects on patient well-being because it causes death. Quality indicators 6-10 aims at assessing treatment and care provided to prisoners such as number of patients receiving proper treatment regimen and number of patients with HIV infection receiving antiretroviral treatment. Unless the prisons reach the desirable results, local health authorities and prison authorities will help the prison to improve the situation. Last, inadequate management in TB services in prisons can escalate health care cost. Quality indicators 11-15 assess the management including an infection control system, TB awareness among prison staff. These would help encourage and collaborate everyone in the prisons to end TB in prisons.

TB services in prisons had varied, and the quality assurance about TB services was not available at that time; therefore, the quality assurance (QA)was firstly developed in 2016, and it routinely continues afterwards. A handbook was developed, and 15 quality indicators were used to cover all aspects of TB services. The auditors who assess the quality are from Department of Disease Control, and prisons providing quality TB services receive a certificate. Since the beginning of the QA, out of 132 prisons, 82.5% participated in the QA, and 85.3% demonstrated quality TB services.

The measurement method of quality assurance including nominators and denominators is original, but the definitions of some quality indicators was adapted from the International Standards of TB Care (ISTC). The ISTC was developed by TB CARE which was a group of international experts from international organisations (Reference: TB CARE I. International Standards for Tuberculosis Care, Edition 3. TB CARE I, The Hague, 2014). The adaptation includes indicator 1-2 (screening), 3 (diagnosis), 7-8 (treatment), 9 (care), 10 (Laboratory), 11-12 (drug resistant TB), 13 (recording and reporting), 14-15 (HIV care), 18 (contact investigation), 20 (TB infection control) and 21 (case notification).

The initiative was introduced in 2016 and was gradually scaled up across the country. In 2016, there were only 27 prisons participating in the quality assurance. After that, 58 new prisons participated in 2017 and then 24 prisons participated in 2018. The number of prisons in 2018 is smaller than in 2017 because the certificate of quality TB services covers two years; thus, prisons participating in 2017 did not need to participate again in 2018. In total, 109 prisons sentencing 274,765 prisoners participated in quality assurance about TB services in prisons.

Implementing quality assurance about TB services in prisons focuses on system integration without disruption of other disease programmes. Five key stakeholders are: (1) National Health Security Office provides on-top budget for TB screening and capitation budget for treatment for prisoners; (2) Bureau of Tuberculosis provides budget and staff for development and evaluation; (3) The Offices of Disease Prevention and Control spends their budget and have their staff visit prisons to measure the quality; (4) Provincial health offices and local hospitals spends budget to implement TB services in prisons; and (5) prisons use their budget to arrange the TB services.

The initiative has been implemented for three consecutive years (2016-2018) because motivations for prisons’ participation could be influenced by the expectation from the public. Prisons can use the QA certificate as a reference of their TB services. According to economic aspects, QA is integrated into routine work which no extra budget is required. TB services in prisons are routinely provided by the budget of National Health Security Office and Department of Corrections. The QA is integrated into supervision routinely provided by the Office of Disease Control and Prevention. Likewise, Department of Corrections has included TB infection control as one of five performance indicators which all prisons have to achieve. Regarding social aspects, the results of QA were made available to the public via an official website of Bureau of Tuberculosis (www.tbthailand.org) As disseminated, the results lead to responsiveness, transparency and accountability of all related agencies and citizens. This communication channel helps ensure sustainability of the initiative because the public know how many prisons provide quality TB services. For the environmental aspect, QA has a two-year round, thus prison environment such as ventilation, isolation room, fan installation is assessed biannually. This helps guarantee the sustainability of the environment in prisons.

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The initiative was evaluated through internal evaluation. A working group with 14 members was officially appointed, and the permission to use prisons as an evaluation setting was officially agreed by the Director General of Department of Corrections. The evaluation method uses retrospective design to review scores of quality indicators over the past three years (2016, 2017, and 2018). Also, each quality indicator was examined to assess which indicators have been most achieved and which ones have been least achieved.

Logic model was used to evaluate the initiatives, so input indicators, process indicator, and output indicator were used for the internal evaluation. First, input indicators included activities such as the handbook of QA, the official letters to endorse the national policy to encourage prisons to participate in the QA, and the certificate of providing quality TB services. Second, process indicators was number of prisoners, which were disaggregated by sub-regions, participated in the QA. Last, the output indicator was number of prisons showing quality TB services inside prisons

Input including the QA handbook, official endorsement, certificates could contribute to the process. However, new auditors as an input might not be able to perform the QA because it reported that prisons where new auditors worked did not participate in the QA. For the output evaluation, number of prisons showing quality TB services increased from 11 prisons in 2016, to 59 prisons in 2017, and to 28 prisons in 2018. However, 16 prisons could not demonstrate quality TB services. Finally, 21 prisons did not participate in the QA, while 2 prisons participated, but their results could not be located.

Although Bureau of Tuberculosis is a focal point, stakeholder engagement is a key factor of the initiative. In early fiscal year of 2016, representatives from both Department of Corrections and Ministry of Public Health developed the handbook of QA for TB services in prisons together. Then the Permanent Secretary of Ministry of Public Health made QA for TB services in prisons effective by signing a letter and distributed to all provinces. Prior to QA implementation, quality indicators were reviewed by provincial health officers, hospitals and prisons to encourage stakeholders’ participation. Moreover, programme staff from Office of Disease Prevention and Control (ODPC) are auditor who are independent from prisons and provincial health offices. Their responsibilities are not only to assess the quality, provide both oral feedback onsite and official feedback few weeks later after completion of EQA and submit an official report to Director General of Department of Disease Control, but to provide technical assistance to the provincial team if required. At the country level, Bureau of Tuberculosis analyzes the results and forwards the summary and certificates of QA to both the Director General of Department of Disease Control and Department of Corrections for signing.

There have been some lessons learned during the past three years. First, the high participation rate of prisons in the QA is possibly due to the ownership of stakeholders. Second, prisons which demonstrate quality TB services should be acknowledged while prisons which do not should receive support from related organizations. This can help prisons to keep up good work. Third, the quality indicators need to be updated because the knowledge frequently changed. Last, reasons that some prisons have not participated in the EQA should be carefully explored then an approach to motivate for their participation can be identified.