Results from an active case-finding project on Nias Island, Indonesia


Results from an active case-finding project on Nias Island, Indonesia

Results from an active case-finding project on Nias Island, Indonesia

Background

Indonesia has one of the highest tuberculosis (TB) burdens in the world, with over 8% of the global TB cases in 2018. In 2018, 563,879 TB cases were notified, the third-highest in the world after India and China. Nevertheless, Indonesia is also one of the main contributors to the increasing gap in undetected and/or undiagnosed cases in the world (10%). Indonesia’s island geography makes access the healthcare services and health information a challenge, and the relative poverty of the rural population makes them vulnerable to catastrophic healthcare costs. The WHO has urged the need for intensified case detection strategies as well as improved accessibility to services in countries contributing to the missing TB cases.

Nias is an archipelago off the western coast of Northern Sumatra that consists of 129 islands, 32 of which are inhabited. The largest island is also called Nias.

Many of the 32 islands are difficult to reach and are only accessible by boat. The overall health care in the Nias islands is of poor quality due to, among other things, limited government funding for permanent healthcare staff in remote areas. Furthermore, the turnover of healthcare staff is high, as many prefer to work in less isolated locations.

 

Nias is one of the poorest areas in Sumatra, and many of the indigenous residents are illiterate and do not speak Bahasa, limiting their understanding of TB information and resulting in low TB awareness.

 

 

TB REACH Intervention

Yayasan Menara Agung Pengharapan Internasional (YMAPI), a local non-governmental organization based in North Sumatra, Indonesia, began working on TB education and awareness in Nias in 2008. From October 2014 to March 2016, YMAPI was awarded a TB REACH Wave 4 (W4) grant where they piloted a multi-pronged TB intervention in a selected area of one district of Nias (South Nias), with the support of the Indonesian National TB Program (NTP). It aimed to increase the number of individuals that were detected, tested and initiated on TB treatment, as well as ensuring adequate follow-up and treatment support.

The core of the intervention was the use of community-based volunteers (health promoters) who were trained and supervised by project staff (health facilitators) to raise TB awareness in the intervention communities. The success of the W4 project led to YMAPI being awarded TB REACH Wave 5 (W5) funding to expand its intervention to three more districts (North Nias, West Nias and Nias). The team trained 1,550 female and 5 male health promoters in the W4 project and 3,730 health promoters in the W5 project. Health facilitators travelled to hard-to-reach areas for screening and identification of people with TB and linking them to diagnosis and treatment. Also, the project purchased 12 microscopes to increase laboratory capacity in Nias.

 

Intervention Activities

 

TB REACH Evaluation Framework

The TB REACH Monitoring and Evaluation framework was applied to assess the impact of the intervention. This framework enables additional case notifications in the evaluation (intervention) and control population to be calculated. Below are a few definitions used in the framework:
Target population: the population affected by the intervention
Evaluation population (EP): the population in which notification data will be evaluated; includes the target population
Control population (CP): a population similar to the evaluation population, but not part of the intervention
Historical baseline trend : a trend of TB case notifications over the past three years in the evaluation population
Additional TB cases : a case that would not have been notified in the absence of the intervention; calculated by subtracting the historical baseline from the current TB notifications

 

Key Results

Effect of the project on TB case notification
Both the W4 and W5 projects were very successful in increasing the number of TB patients notified to the NTP and put on treatment. In the W4 project,

178 more patients (154%) were notified compared to the baseline, while the control showed a decrease of 41%. After adjusting for historical baseline trends, the intervention showed an increase of 225% in case notification and a decrease of 17% in the control population.

 

Similar success was seen in the W5 intervention, where TB case notifications increased by 87% compared to baseline, equating to a 71% increase after adjusting for baseline trends. In contrast to the W4 project, which showed a decrease in case notification in the control population, during W5, an increase of 59% in case notification (with baseline adjustments) was also seen in the control populations.

This increase may be explained by the indirect influence of the intervention on these areas, as the control population was also selected from Nias island.

 

Successes

Throughout its implementation, the project has had great success in increasing case-finding, notification, treatment initiation and treatment outcomes within the target population. The data clearly shows that the project was able to significantly improve TB case-finding in the evaluation populations as shown by increased TB notifications in the SITT (Sistem Informasi Terpadu TB – the national TB reporting system). The project team noted that government officials (district TB officers, and chief of districts) were very pleased with YMAPI’s work, as illustrated by the quote below from the District Development Agency in Nias District:

“Pemkab seharusnya menyambut baik program ini dan mendukung YMAPI dalam pelaksanaannya karena hasil dari project sebelumnya sangat baik dampaknya bagi Kabupaten Nias.”

“Our district government should welcome and support the implementation of the YMAPI project as the previous project has had a very good impact on our TB program in Nias.”

The project showed how groups of community volunteers (health promotors) at the grass-root level, can be successfully used to improve TB care, even without the provision of financial incentives. In the W4 intervention, the health promoters covered 112 villages and in W5 they covered 299 villages. During advocacy meetings, YMAPI advocated for the government to commit to requiring laboratory workers to work at the same puskesmas for at least two years. The government hired contractual staff to replace volunteer staff in several Puskemas.
The project’s strong advocacy at the district health office for better TB care has led to at least one district agreeing to increase its TB care budget. In 2019, YMAPI was granted a 1-year W5 scale-up project running until the end of March 2020, where activities were further expanded to cover the whole of Nias and to 4 remote districts on the mainland of North Sumatra. The first results are very positive.

Building on success

This project has successfully increased TB case notification on Nias Island. In 2018, Indonesia was one of the two countries that contributed the most to the global increase in case notifications. The project encompasses a component of increasing community awareness through TB awareness campaigns. This will allow the communities to be more educated with respect to their rights and to TB in general. This intervention has shown that community volunteers (who receive no financial incentives) can be used effectively to identify people with the signs and symptoms of TB. Further funding and support to the YMAPI intervention will enable an even larger increase in the number of case notifications and even more patients to be treated. If these efforts are continued and scaled-up, they will play a significant role in helping to reach the UN’s End TB Strategy goal of eliminating TB by 2035.

Tags: , ,

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.