Despite nationwide DOTS coverage with high treatment success rates, a number of challenges still exist in the control and prevention of TB in Tanzania. They include:
• Delays by patients in seeking care when TB symptoms set in.
• Passive participation of the community in TB care and control.
• Stigma associated with TB and HIV.
• Poor adherence to anti-TB regimens, leading to an increased threat of drug-resistant TB.
To address these challenges, the MOHCDGEC, in collaboration with implementing partners, introduced a community TB care approach to involve communities and former TB patients across the country to improve early TB care-seeking and treatment adherence, increase community awareness around TB symptoms and signs, and mitigate TB stigma. The resulting outcome will contribute to increased case detection and treatment success, thereby contributing to attainment of the MDGs and reduction of poverty.
Community TB care represents a wide range of activities carried out at the community level by community members themselves, in partnership with community health care workers who serve as a link to the health care system. Community TB care also includes activities to promote effective communication, community empowerment, and participation to generate demand for and improved quality of TB prevention, diagnosis, treatment, and care services.
The combined effect of a well-implemented package of activities for community TB care activities should lead to the following outcomes:
• Empowerment of communities to take appropriate actions to address community TB burden.
• Reduced congestion in health care facilities, thus reducing the workload of facility-based health care workers and raising the quality of interactions between health care workers and patients.
• Reduced likelihood of emergence, expansion, and transmission of drug resistance through
enhancement of adherence to both first- and second-line anti-TB treatment.
The expected long-term impact of these interventions is a reduction in TB incidence, prevalence, and mortality.
Approaches to community tuberculosis care
ENGAGE-TB
The MOHCDGEC, in collaboration with WHO and other implementing partners, has developed a guideline to engage civil society organizations (CSOs) in TB care and control. The proposed approach has been given the name “ENGAGE-TB” and comprises the following six components (see also Figure 9):
• Creating an Enabling environment
• Developing New tools
• Gathering information
• Assessing tasks
• Getting the evidence
• Enhancing capacity
Six Components of ENGAGE-TB approach.
Situation analysis: CSOs should conduct a situation analysis to identify the specific needs and tasks that will be undertaken to integrate community TB control activities into their plans for implementation. The analysis should involve information-gathering at the respective level of their jurisdiction to analyze and understand the existing situation before implementation of TB control activities.
ii. Enabling environment: The MOHCDGEC has established ENGAGE-TB policies and operational
guidelines to enable effective engagement of CSOs in TB control activities. Regions and districts have to ensure a good environment for ENGAGE-TB implementation in their respective areas according to national policies. The established National CSOs Coordinating Body, which represents the interests of ENGAGE-TB approach CSOs, should systematically share and disseminate lessons learned by individual member organizations.
iii. Guidelines and tools: National operational guidelines for ENGAGE-TB, and community TB care handbook for community health workers in complement with other NTLP guidelines, should be used by CSOs to implement TB control activities at the community level.
iv. TB task identification: TB is intricately linked with HIV and is also closely related to social
determinants of health and non-communicable diseases such as poverty, crowding, malnutrition, drug and alcohol abuse, and diabetes mellitus. Therefore, the task identification needs to consider the opportunities, capacities, and comparative advantages of the CSOs working in such areas and decide how best to address TB in their target populations and areas of work.
v. Monitoring and evaluation: Engagement of CSOs in delivery of community-based TB activities should be routinely monitored to inform their contribution to TB control and to ensure quality and effectiveness of their involvement. CSOs should ensure that planned activities are aligned with MOHCDGEC policies and guidelines. Existing standardized TB forms and registers must be used and linked with the national TB monitoring and evaluation system to allow recording of the contribution of community-based TB activities to national TB control efforts.
vi Capacity-building: CSOs engaged in TB activities should conduct needs assessments to identify the capacity and skills needed by health care workers, community health workers, and volunteers to implement identified community-based TB control activities.
Patient-centered treatment (PCT)
PCT makes it easier for patients to complete their treatment without compromising the principles of directly observed treatment. It has been recognized that health facility based directly observed treatment puts too much demand on patients and health care workers.
In PCT, TB patients are given an option to choose where they would like to be supervised during their daily treatment, either at a health facility or at home. A patient who chooses to be supervised at a health facility will receive their daily treatment under the supervision of a health care worker. A patient who chooses to take daily treatment at home will be supervised by a treatment supporter of his/her own choice who has been trained in directly observed treatment and how to record daily medication.
Health care workers should provide patients and families with basic information on TB, including reassurance that TB is curable; the treatment process and duration; drug side effects including how to identify them and what to do if they occur; and the importance of adhering to and completing treatment. Explain the necessity of directly observed treatment either in a facility or at home communicate with patients and their families in a supportive manner and be ready to answer their questions.
Note: The choice of receiving treatment in a facility or at home can only be offered to new patients.
Previously treated TB patients can only be offered this choice after they have completed the first two months (initial phase) of treatment which includes daily streptomycin injection.
Community TB care groups
A wide range of community members, including CBOs, religious groups, and current and former TB patients should be encouraged to participate in TB care and control. These community groups should be consulted when defining the roles that they should play in the community TB care and control effort. A topdown approach should be avoided. A consultative process with consensus-building around roles and responsibilities of the community vis-à-vis those of the health care system is likely to result in a stronger partnership between the health care system and the community and enhanced community ownership of the program. The tasks that may be undertaken by community groups are highlighted above.
