Access to TB care in Madagascar is severely limited, despite a free TB care policy. The estimated TB incidence in Madagascar has remained largely unchanged since 2013, with 233 cases per 100,000 people. In 2020, only 36,000 new or relapsed TB cases were officially reported, representing just 55% of the estimated total TB incidence by the World Health Organization (WHO). Barriers in accessing TB care are primarily due to the country's healthcare system being significantly underfunded.
To address this issue, a pilot program called mirayTB has been implemented in a rural district within the Atsimo-Andrefana region. This region is not only the largest but also the poorest in Madagascar: The majority of the population in the region experiences extreme poverty, compounded by frequent natural disasters that lead to food insecurity and a state of chronic humanitarian crises. The primary implementation district Ampanihy-Ouest has a population of approximately 400,000 people as of 2018. In Ampanihy-Ouest, six out of ten people (60%) reside in hard-to-reach areas situated at least 5 kilometers away from the nearest primary healthcare center. These populations can only access healthcare centers by foot, exacerbating the difficulties in obtaining TB care.
MirayTB acts as an enhancing agency. In collaboration with local communities, health facilities, and national and international stakeholders, and through its multi-pillar approach, the initiative aims to effectively and sustainably reduce barriers to accessing care and improve chances of recovery for individuals affected by TB.
COMMUNITY
Local communities including community health workers (CHWs) play a crucial role in raising awareness about TB, facilitating screenings, and supporting patients in completing their treatment. Thus, the involvement of CHWs is vital to our activities. CHWs receive comprehensive training on essential aspects of the disease, including transmission dynamics, screening methods, and treatment aspects. Regular CHW meetings ensure the share of experiences and enable discussions regarding bottlenecks and challenges in delivering their services. CHWs are partially provided with bicycles and mobile phones, enabling them to more effectively reach remote areas and facilitate communication with the project team.
CHWs initially engage with communities through mass sensitization campaigns. The primary objective of these campaigns is to acquaint the community with the prevailing TB threat and to disseminate crucial information about the disease. Based on our observations, this approach enables meaningful interactions within the community and paves the way for the acceptance of treatment measures. Through this concerted effort, individuals are motivated to actively seek and successfully complete the necessary treatment. Furthermore, it encourages the community to prioritize effective preventive measures against TB.
Local musicians are also contributing by conveying messages through musical performances. This creative approach aids in effectively delivering the messages. Additionally, in some instances, individuals who have undergone treatment for TB in the past may also play a significant role in sensitizing their fellow residents about the disease.
DECENTRALIZATION
In the intervention region, the majority of designated TB care centers are not operationally active. This adds up to the already existing geographic and logistical challenges faced by people in hard-to-reach areas to access TB care. The aim of decentralizing facility-based TB care is to bring TB care closer to the communities, ensuring that people have easier access to screening, diagnosis, treatment, and support. mirayTB therefore focuses on three aspects:
NUTRITIONAL SUPPORT
Food insecurity has a significant impact on TB treatment and health outcomes. Malnutrition weakens the immune system, making individuals more susceptible to TB infection and reducing their ability to overcome the disease effectively. Malnourished individuals may also experience challenges in tolerating TB drugs and may have a higher risk of developing adverse drug reactions. Thus, integrating nutritional support into TB programs is crucial. In our efforts to address the nutritional needs of malnourished people with TB, mirayTB supports individuals in accessing food support through the World Food Programme (WFP). The project team ensures the distribution of monthly food support packages provided by WFP, including fortified blended food ('Super Cereal'), a specialized food product that is enriched with essential nutrients, vitamins, and minerals and sunflower oil.
To facilitate access to nutritional support, food distribution is incorporated into routine mobile TB clinics. In addition to providing food support, the mirayTB project team in collaboration with CHWs provides educational counseling on healthy nutrition for people with TB, transferring knowledge about the significance of specific nutrients, locally available nutritious foods, and meal planning.
ADVANCED CARE (MDR-TB)
When faced with treatment failure due to drug-resistant TB, additional challenges come up. The limited availability of laboratories offering resistance testing and reference hospitals being exclusively located in regional capitals present significant challenges for individuals and their families. mirayTB provides the following support to increase access:
MirayTB's team operates under the umbrella of an NGO that oversees multiple healthcare projects in Madagascar. We are fortunate to receive support from the NGO's general administrative team, which primarily focuses on financial, logistical, and human resource administration. However, it is important to note that all other aspects of operational administration are managed at the project level. This includes activities such as project planning, implementation, monitoring, and evaluation. Our project team ensures the smooth operation of the TB mobile clinics, coordinating with local partners, healthcare professionals, and community stakeholders.
Roles:
National TB program: In Madagascar, establishing TB service provisions necessitates formal approval and support from the national TB program, the "PNLT" (Programme National de Lutte contre la Tuberculose). Collaborating with the PNLT is not only a procedural requirement but a crucial step for MirayTB to engage in assessments and interventions related to TB care. Additionally, forging connections with key partners such as regional and district health authorities (Madagascar: “Direction Régionale de la Santé Publique”), local public health care centers, and local authorities (including village chiefs; Madagascar: “Chefs Fokotany”) is integral.
By aligning with the priorities and guidance of regional and district authorities, MirayTB ensures that its TB care interventions integrate into the functioning of existing diagnostic and treatment centers for TB care. This collaborative approach goes beyond formalities, aiming to address specific local needs and enhance the project's long-term impact. Operating within the framework established by regional and district authorities, this collaboration strengthens sustainability and ensures the project's effectiveness.
Nutritional support programs: In order to establish contact and evaluate the operations of preexisting nutritional support programs in the region, such as the World Food Programme (WFP), it is important to initiate communication at both the national and regional levels. Patients who experience the dual burden of tuberculosis (TB) and malnutrition are eligible for food support. Through the implementation of MirayTB, the logistics of food distribution can be established and enhance the reach of existing nutritional support programs.
Technical groups: In addition to the PNLT, there are other technical groups that bring together various stakeholders involved in TB care at the national level. These groups provide a platform for collaboration and knowledge exchange, offering valuable recommendations on how to enhance current intervention practices. Engaging with these technical groups early on can provide important insights and recommendations for improving the effectiveness and efficiency of TB interventions.
Assessing baseline conditions for TB care in Madagascar is a crucial step in comprehending the prevailing challenges and gaps in the healthcare system. Approval from the aforementioned healthcare authorities is imperative for this process. This assessment lays the groundwork for designing targeted interventions and measuring progress over time. The procedures employed during the assessment include surveys, focus group discussions, individual interviews (with beneficiaries, partners, experienced health agents, and community representatives), as well as site visits and fact-finding trips. In the context of MirayTB, key components during a baseline assessment include:
Regional level
Facility level
Patient level
Defining the project zone necessitates a collaborative decision-making process involving all stakeholders mentioned earlier, such as the National TB Program (PNLT), regional health authorities, and the CDTs and CTs included in the project. Drawing upon inputs and feedback from these stakeholders, a collective decision is made to define the project zone. This decision-making process considers identified areas with low access to TB services, geographical factors, available resources, and particularly vulnerable populations. Additionally, it is essential to highlight that the available budget and anticipated costs for the intervention must be incorporated early into the planning of the project zone. This financial consideration ensures that the chosen project zone is not only strategically aligned with health priorities but also feasible within the allocated budget.
A predefined timeline is equally important. We collaborate with the partnering organizations to establish a timeline for the training and facility rehabilitation activities. Consider factors such as the availability of trainers, the capacity of health workers to participate in training, and any geographical or logistical constraints that may affect the realisation. To ensure continuity, sustainability, and maximize the impact of the project, it is crucial to consider the following aspects during the initial timeline discussions: 1) Agree on a minimum project duration: Two years for MirayTB 2) Discuss long-term prospects: Evaluate the approach and establish it in national guidelines 3) Plan for knowledge transfer: Health care professionals and TB care authorities should be capacitated to implement the program 4) Evaluate scalability: Establish common baseline strategy that can be applied in different regional settings.
Once a mutually agreed-upon project zone and timeline is established, we document it in the collaboration agreement. Start and end dates of each activity, as well as any intermediate milestones should be included.
We further discuss the terms and conditions of the collaboration. This includes defining the scope of collaboration, roles and responsibilities of each party (see 1.1. Team Building ), expected outcomes and how to measure them (see 3. Monitoring and evaluation), resource sharing (see 1.7. Equipment procurement), confidentiality agreements (see 1.6. M&E), and any financial arrangements.
The scope of collaboration is clearly defined by the independent role of public healthcare workers, with MirayTB functioning as an enhancing agency to leverage outcomes. MirayTB provides essential support by facilitating means of transport for conducting mobile clinics and equipping laboratories and treatment facilities with the necessary equipment to fulfill their work effectively. During the mobile clinics, it is the healthcare professionals who conduct screening and therapy services, while MirayTB plays a vital coordination function between these healthcare professionals and CHW. MirayTB, alongside community health workers, is responsible for the distribution of food support provided by the World Food Program. This involves organizing and managing the logistics of food distribution, ensuring that the nutritional support reaches the intended beneficiaries. Financial arrangements are crucial to ensure the continuous support and dedication of healthcare professionals and CHW in providing TB care services. Sustaining working conditions and providing fair compensation are essential to prevent healthcare workers from seeking alternative employment opportunities outside the healthcare sector to make a living. Health care professionals receive a bonus for each mobile clinic conducted and CHW receive an indemnity for each mobile clinic and additonally performance based bonuses for identifying new patients and enabling treatment success.
Defining monitoring and evaluation (M&E) objectives is the first step in establishing an effective M&E framework. For MirayTB we aim to measure effectiveness of project, to assess the quality of services and identifiy areas for improvement. Based on this we select appropriate key performance indicators. Total number of people screened, rate of positive diagnosis, diagnosis category (TBP+, TBP-, TEP), treatment initiation and treatment success rates are the main outcomes. Other relevant data points in the data collection plan include: number of individuals receiving chimioprophylaxis treatment, HIV tests conducted, and general patient information. Data is collected by the TB Agent, parallel to the required national data collection mechanism. This parallel data collection enables validation and additional data we collect can be used to inform national agencies. MirayTB ensures the privacy and confidential usage of the data by implementing strict access controls. By limiting access to project staff who have a legitimate need for the data, confidentiality is maintained.
We began the project with a paper-based data collection system. A data collection form, based on an individual patient sheet, was designed and standardized among all project sites. The data is transferred from individual patient sheets into an Excel file at the end of each month. This allows for efficient storage and analysis. An organized Excel file with appropriate column headers to correspond with the fields on the patient sheet is needed.
Transition to digital data collection tools is ongoing. To enjoy the advantages in terms of efficiency, accuracy, and data management we are implementing the usage of a data collection software. CommCare serves as our chosen digital data collection software, offering a mobile platform that facilitates customized data collection forms and data entry on tablets or mobile devices. The design of our data collection forms is tailored to align with the specific workflows involved in our field work. We prioritize intuitiveness, enabling our teams to navigate the forms and complete data entries during mobile clinics. This approach helps minimize the risk of missing data entries and enhances overall data quality. The digital platform eliminates the need for manual data entry, reducing the chances of transcription errors and ensuring accurate data capture. Additionally, the use of CommCare enables remote data management. This feature allows us to remotely access and manage the data, ensuring timely data analysis and reporting. It also facilitates real-time monitoring of project progress and the ability to identify trends or areas for improvement promptly.
Prior to the commencement of the project, equipment procurement is a crucial step in ensuring the necessary resources are available for effective implementation. To address the needs identified in the earlier baseline assessment, it is important to ensure the availability of the following equipment items:
Pillar “COMMUNITY”:
Pillar “DECENTRALIZED CARE”:
Pillar “NUTRITIONAL SUPPORT”:
Pillar “ADVANCED CARE”:
Description: Our large-scale awareness campaigns are designed to inform communities about the existing threat of Tuberculosis (TB) and the essential aspects of TB care. In close collaboration with the program's TB Agent, local Community Health Workers (CHWs) utilize various means, including public speeches, singing campaigns, and focused group discussions held during market days. The goal is to convey the ten key messages about TB as outlined by PNLT Guidelines, effectively informing and sensitizing communities about TB prevention, symptoms, and treatment.
Purpose: The primary objective is to raise awareness within communities, initiate open dialogue, and disseminate crucial information about TB. Aligned with national guidelines for TB prevention and care, these efforts strive to empower communities with knowledge, fostering proactive engagement in TB prevention and care initiatives.
Description: CHWs conduct visits to households, screening individuals for TB symptoms and informing about TB prevention and treatment. These visits also serve to announce upcoming mobile clinics, ensure ongoing participation beyond the initial treatment initiation and offer chemoprophylaxis for children under the age of five living in a household with person diagnosed with TB infection. In remote communities, CHWs additionally distribute medication treatments during these home visits to pre-identified TB patients.
Purpose: This initiative represents a targeted outreach to individuals, fostering a more personalized approach to TB care. Household visits empower CHWs to directly engage with individuals in their homes, ensuring continuity of care and reinforcing the importance of ongoing participation in treatment and clinic activities.
Description: Regular gatherings of CHWs for information dissemination, training, and coordination. These meetings serve to reinforce sensibilisation topics and enhance their capacities. We have implemented a training program, and during monthly assemblies, we focus on capacity-building through additional training sessions, motivating CHWs through performance-based bonuses. Bonus incentives include materials for sensitization, AC bonuses, and other tangible rewards.
Purpose: The primary goal is to enhance CHW knowledge, skills, and collaboration for effective TB awareness and intervention. These meetings provide a platform for continuous learning, ensuring that CHWs are well-equipped to address TB-related challenges in their communities. Traditionally, CHWs in Madagascar have voluntarily carried out tasks related to TB care and prevention. Recognizing the crucial role they play, we introduced a low monetary value performance-based bonus scheme, incentivizing CHWs for referring patients with suspected TB to a TB care provider. Payments are facilitated through the use of mobile money technology provided by local network providers. This initiative not only recognizes their efforts but also ensures more effective community engagement in the fight against TB.
Description: Mobile healthcare units that travel to different locations to provide on-the-spot TB diagnosis, treatment, and education. To overcome geographical barriers, we introduced motorbike-based mobile clinics staffed by members from district-level TB care facilities and local mirayTB teams. These clinics are conducted biweekly in selected villages, strategically chosen for accessibility to remote communities. The median distance (one-way) from the TB care facilities to the mobile sites was 42 km (range = 18 – 100 km one-way). Scheduled on market days, the clinics optimize patient participation and reduce opportunity costs. Specimen collection for diagnostic purposes is performed by either CHWs or TB care staff from the mobile clinics. Depending on travel time, laboratory technicians process samples on-site or at the laboratory upon return. TB care staff administer a daily regimen containing six months of rifampicin (2HRZE, 4HR) following national guidelines. Additionally, chemoprophylaxis treatment is provided for children under the age of five living in a household with a person diagnosed with TB infection. The clinics utilize patient registration sheets, gather essential data such as weight and height, and prioritize implementing digitalization for efficient data collection, reducing reliance on paper documents. This approach facilitates close monitoring of TB patients.
Purpose: The primary goal is to increase access to TB services, particularly in remote or underserved areas. Mobile outreach clinics aim to address geographical challenges, ensuring that individuals in these areas have convenient and regular access to TB diagnosis, treatment, and education.
Description: Provision of nutritional assistance to TB patients, addressing the crucial link between nutrition and TB treatment outcomes. Through a collaboration with the World Food Programme (WFP), we secure food support for vulnerable populations, specifically targeting TB patients. WFP supplies essential food items such as rice, soy powder, and vegetable oil, while our field staff ensures the regular distribution of these provisions among malnourished TB patients during mobile clinics and at the diagnostic and treatment centers.
Purpose: The primary goal is to enhance patient well-being, support recovery, and improve treatment adherence. By addressing nutritional needs, especially among malnourished TB patients, we aim to complement the overall treatment approach and contribute to more positive treatment outcomes. The distribution of nutritional support also serves as an additional incentive to visit the mobile clinics, encouraging patients to actively engage in their TB care.
Description: Implementation of diagnostics for drug-resistant TB and facilitating referrals for specialized treatment. We organize the transport of sputum probes for suspected MDR TB cases (patients resistant to treatment) to district or regional level laboratories that exclusively offer this analysis. We ensure the results reach the patients, and in the case of a positive test result, we provide financial support for transferring the patient to regional treatment facilities. Additionally, we offer financial support for the nutrition and stay of family members accompanying the patient.
Purpose: The primary goal is the early detection and management of drug-resistant TB cases, aiming to prevent further spread of the disease. By implementing specialized diagnostics and ensuring timely referrals, we contribute to more effective and targeted interventions for individuals with drug-resistant TB, improving their chances of successful treatment and reducing the risk of transmission within the community.
Description: Quality improvements encompass conducting training sessions, implementing data collection improvements, and providing materials and infrastructure enhancements for local health facilities. Training sessions involve local public health staff, including medical doctors, nurses, and laboratory technicians, as well as CHWs, focusing on TB diagnostics, treatment, and counseling on treatment adherence. Data collection processes are enhanced through the implementation of a digital platform that works offline, ensuring on-site data collection and enabling a direct linkage with laboratory results. We equipped TB care facilities with necessary instrumental equipment (lab equipment, scales, and other complementary items) based on their needs and renovated building infrastructure, prioritizing laboratory spaces and providing amenities such as air conditioning and reliable electricity supply. A bonus scheme is implemented for local health care staff engaged in TB work, based on patient outcomes. Payments are facilitated through the use of mobile money technology provided by local network providers. Additionally, a coordination and support team was established in each intervention district, consisting of one coordinator and two field workers. Each mobile clinic is accompanied by a field worker to ensure a sufficient human workforce for clinical work and programmatic data collection. The regional coordination team of the National TB Program co-supervised all activities through field visits every three to four months.
Purpose: Creating an environment conducive to efficient and effective TB diagnosis, treatment, and support. The goal is to enhance infrastructure, provide necessary training and incentives, and establish a coordinated support system to improve overall TB care delivery. The modifications in treatment schemes, including replacing the daily directly observed treatment scheme (DOTS) with an observed treatment every two weeks and fostering the linkage between patients and CHWs, aim to reduce opportunity costs and improve treatment adherence.
Project Management:
Communication:
Assessments are conducted through ongoing monitoring and follow-up of program activities, involving both mirayTB's field staff and personnel from local healthcare facilities. The project manager conducts regular supervision visits, allowing for the assessment of needs and consideration of suggestions for improvement. Different project sites may vary in the required frequency of mobile TB outreach clinics, staffing needs for proper screening and data collection, and population-specific requirements.
Identifying bottlenecks, such as transportation challenges, procurement of equipment or consumables, and collaboration with other stakeholders, is crucial. Active involvement of the program manager is essential in addressing these challenges and ensuring the smooth operation of the program.
Data-based Evaluations:
To ensure the collection of the mentioned numeric indicators, it is crucial to organise program data collection.
Scientific evaluations are essential for assessing both qualitative and quantitative aspects of patient needs, the local context, and program performance. Continuous engagement in research activities allows for ongoing improvement of the program and facilitates the sharing of knowledge and experiences gathered throughout its implementation. This commitment to research contributes to the evolution and refinement of the program based on evidence and best practices.
Collaborations with key local stakeholders, local researchers, and international research institutes, such as the Charité Center for Global Health and the Heidelberg Institute for Global Health, have proven to be fruitful, fostering the exchange of ideas and mutual learning.
MirayTB is a non-profit initiative by Charité - Universitätsmedizin Berlin and Doctors for Madagascar in collaboration with the Malagasy National TB Program.
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