International non-governmental organizations' provision of community-based tuberculosis care for hard-to-reach populations in Myanmar, 2013-2014.
BACKGROUND
National tuberculosis (TB) programs increasingly engage with international non-governmental organizations (INGOs), especially to provide TB care in complex settings where community involvement might be required. In Myanmar, however, there is limited data on how such INGO community-based programs are organized and how effective they are. In this study, we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar, and assess their contribution to TB case detection.


METHODS
We conducted a descriptive study using program data from four INGOs and the National TB Program (NTP) in 2013-2014. For each INGO, we extracted information on its approach and key activities, the number of presumptive TB cases referred and undergoing TB testing, and the number of patients diagnosed with TB and their treatment outcomes. The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.


RESULTS
All four INGOs implemented community-based TB care in challenging contexts, targeting migrants, post-conflict areas, the urban poor, and other vulnerable populations. Two recruited community volunteers via existing community health volunteers or health structures, one via existing community leaderships, and one directly involved TB infected/affected individuals. Two INGOs compensated volunteers via performance-based financing, and two provided financial and in-kind initiatives. All relied on NTP laboratories for diagnosis and TB drugs, but provided direct observation treatment support and treatment follow-up. A total of 21 995 presumptive TB cases were referred for TB diagnosis, with 7 383 (34%) new TB cases diagnosed and almost all (98%) successfully treated. The four INGOs contributed to the detection of, on average, 36% (7 383/20 663) of the total new TB cases in their respective townships (range: 15-52%).


CONCLUSIONS
Community-based TB care supported by INGOs successfully achieved TB case detection in hard-to-reach and vulnerable populations. This is vital to achieving the World Health Organization End TB Strategy targets. Strategies to ensure sustainability of the programs should be explored, including the need for longer-term commitment of INGOs.
Department of Medical Research, (Pyin Oo Lwin Branch), Ward 16, Near Anisakhan Airport, Pyin Oo Lwin Township, Mandalay Region, Myanmar. kyawthusoe.dmr@gmail.com.
Kyaw Thu
http://orcid.org/0000-0003-0969-8815
KT
Soe
Department of Medical Research, (Pyin Oo Lwin Branch), Ward 16, Near Anisakhan Airport, Pyin Oo Lwin Township, Mandalay Region, Myanmar.
Saw
S
Saw
Institute of Tropical Medicine, Nationalestraat 155, Antwerp, 2000, Belgium.
Johan
J
van Griensven
National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, 207 Ruijin Er Road, Shanghai, 200025, People's Republic of China.
Shuisen
S
Zhou
Department of Medical Research, (Pyin Oo Lwin Branch), Ward 16, Near Anisakhan Airport, Pyin Oo Lwin Township, Mandalay Region, Myanmar.
Le
L
Win
Jawaharlal Institute of Postgraduate Medical Education and Research, No-1, Vinayagar kovil Street, Kathirkamam, Puducherry, 605009, India.
Palanivel
P
Chinnakali
Operational Research Unit, Médecins Sans Frontières, Operational Research Unit, 68, rue de Gasperich, Luxembourg City, L-1617, Luxembourg.
Safieh
S
Shah
Department of Medical Research, (Pyin Oo Lwin Branch), Ward 16, Near Anisakhan Airport, Pyin Oo Lwin Township, Mandalay Region, Myanmar.
Myo Myo
MM
Mon
National Tuberculosis Programme, Disease Control Unit, Nay Pyi Taw Bed 1000 Hospital, Zabu Kyatthayay road, Zabu Thiri Township, Nay Pyi Taw, Myanmar.
Si Thu
ST
Aung
D003153:Community Health Services / Q000458:organization & administration; D003150:Community Health Workers / Q000458:organization & administration; D003430:Cross-Sectional Studies; D023801:Directly Observed Therapy; D062305:Geographic Mapping; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D007390:International Agencies; D007391:International Cooperation; D002052:Myanmar / Q000453:epidemiology; D009938:Organizations / Q000458:organization & administration* / Q000592:standards; D057766:Policy; D014171:Transients and Migrants / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014376:Tuberculosis / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy* / Q000635:transmission; D014838:Volunteers; D035862:Vulnerable Populations; D014944:World Health Organization
Community; Contribution; International non-governmental organizations; Myanmar; Operational research; Tuberculosis; Volunteers