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Independent Evaluation Report on the IFRC/RRC Programme for Comprehensive Tuberculosis Control in Belgorod Region

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Independent evaluation report on the IFRC/RRC programme for comprehensive tuberculosis control in Belgorod Region September 2008 This report reflects the findings and opinions of an independent evaluation team consisting of: Dr. Michael Pelly MB MSc (Clin Trop Med) FRCP Chelsea and Westminster Hospital DTM+H NHS Foundation Trust 369 Fulham Road SW10 9NH London United Kingdom Dr. Thyra E. de Jongh MSc DIC PhD Centre for Health Management Imperial College Business School South Kensington Campus SW7 2AZ London United Kingdom Dr. P. Sai Kumar MD MPH Imperial College Consultants Ltd. 58 Princes Gate SW7 2PG London United Kingdom Contents Summary ........................................................................................................................................1 1. Background .................................................................................................................................4 1.1 Global TB situation ........................................................................................................................ 4 1.2 TB situation in Russian Federation ................................................................................................ 4 1.3 Project Objectives ......................................................................................................................... 6 1.4 Methodology ................................................................................................................................. 6 2. History of Red Cross TB Programme in Belgorod .........................................................................8 2.1 The beginning ................................................................................................................................ 8 2.2 Model for collaboration between TB services and Red Cross ...................................................... 9 2.3 Overview of the USAID/IFRC/RRC TB programme ...................................................................... 10 2.4 Results of collaborative Red Cross TB project ............................................................................ 11 3 Evaluation of the Red Cross TB Programme in Belgorod region .................................................. 16 3.1 Organization of TB services in the region ................................................................................... 16 3.2 TB Programme performance in Belgorod Region ....................................................................... 18 3.2.1 TB burden and notification rates ......................................................................................... 18 3.2.3 Supervision and monitoring of TB services in the region .................................................... 24 3.2.4 Training of medical and paramedical staff........................................................................... 25 3.2.5 DOTS Plus for management of MDR‐TB ............................................................................... 25 3.2.6 TB‐HIV collaborative activities ............................................................................................. 27 3.2.7 Links with the penitentiary system ...................................................................................... 27 4. The way forward ....................................................................................................................... 28 4.1 Contribution of the IFRC/RRC TB project .................................................................................... 28 4.2 The Challenges ............................................................................................................................ 29 4.3 Sustainability ............................................................................................................................... 31 4.4 Recommendations and Future suggestions for RC involvement ................................................ 31 Summary An independent evaluation of the IFRC‐RRC comprehensive TB programme in Belgorod was undertaken by the team from Imperial College, London. The evaluation primarily focussed on the achievements and challenges in the implementation of the USAID assisted TB project in the Belgorod region, with special emphasis on the role of social incentives in improving treatment adherence among the TB patients. The evaluation report is the outcome of detailed review of available project reports, TB performance reports, and interviews with key stakeholders from the IFRC/RRC TB project, regional TB programme staff, policy makers, donors, WHO and more importantly the TB patients. The field visits to collect relevant information and conducting interviews was undertaken between 25th June to 4th July 2008 and 22nd September to 27th September 2008. Russia is currently ranked 11th among the list of 22 high burden countries in the world, and accounts for 36% of the TB burden in the WHO‐Euro region. The resurgence in TB has been the outcome of socio‐economic crisis in the early 90s, breakdown of health care delivery systems including that for TB, and increasing rates of drug resistant TB and TB/HIV infections in the community. The Tb case rates were estimated to be nearly 50 times higher in the penitentiary system as compared to the general population, and were considered to the focal points for transmission of disease. Against this background the Russian Red Cross with support from several development partners initiated a comprehensive TB/HIV control programme in Sept 1999, in collaboration with the department of health, regional governments, TB services, WHO and the community. The project is being supported with USAID assistance since Sept 2001. The essential model for collaboration in the challenging environment of a strong vertical TB structure, and early resistance to globally recommended DOTS Strategy was made possible through an innovative collaborative model. The model clearly identified the areas of collaboration and primarily focussed on health education, capacity building of TB network (both infrastructure and human resource – training), and facilitating convenient patient centred supervised treatment during continuation phase of TB treatment. To improve patient compliance, the project targeted the identified socio‐economically vulnerable groups, especially the unemployed, the difficult patient groups like alcoholics, ex‐prisoners, drug users, and homeless. The major outcomes of the USAID assisted IFRC/RRC TB project is outlined below. Strengthening of relationship between RRC and TB services at national, regional, district and community level. RRC is currently involved at all levels in planning, implementation and evaluation of TB services. Strengthening of TB infrastructure, especially the development of laboratory capacity (including culture and drug sensitivity testing) both within the general health system and in the penitentiary system. The RRC project has provided both technical support and funds for strengthening laboratories, MDR‐TB facilities with novel infection control measures, and TB programme surveillance systems. 1 Significant inputs in building human resource capacity by organizing training workshops, and facilitating training of TB staff at national and international level. Implementation of the social support programme, which involved a mix of patient support and counselling, provision of food and hygiene packets and individualized attention. This has resulted in decline of treatment default rates from a reported high of 30% before the initiation of project to fewer than 5% currently. From the analysis of available data, it has been calculated that on an average the risk of default is 5 times higher among those not receiving social support, as compared to those receiving social support (OR‐ 5.34, 95% CI‐ 3.55‐8.29, p<0.0001). This observation, significantly lays the emphasis for continuing social support packages for improving treatment compliance Strengthening of Visiting Nurse programmes in the regions, that has not only led to improvements in TB service delivery, but is also benefitting the traditional patients who are sick, old and needing support. In some of the regions, including Belgorod, the local governments are providing additional support (funds) for the VHN scheme. In spite of the significant gains, few challenges have been identified which needs to be considered for strengthening the programme and ensuring sustainability of the project. Some of them are highlighted below. Although treatment outcomes in the cohort of patients under RRC are good, it is recommended that the RRC considers extending support and counselling services to in‐patients to improve treatment compliance during the intensive phase of treatment. This would also help in identifying families in need of additional social support. Given the expansion of TB services and inclusion of DOTS Plus services, there will be increased demand for social support. The RRC should develop a strategic 5 year plan (an immediate 2 year plan under the USAID project and a plan for the 3 years beyond that) for the TB/HIV/AIDS project, with special emphasis on estimating resources needed (human resource needs and funds) to undertake expansion of services and activities. The IFRC/RRC should develop a comprehensive plan to engage with federal and regional authorities for increased commitment to co‐financing and budgetary support. Alternate avenues for fundraising, for example through engagement with industry (Confederation of Industries, World
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