1. Understanding determinants and contribution of Myanmar Medical Association Active Case Finding tuberculosis Project: An implementation Research
Kyaw Ko Ko Htet1, Saw Saw1, Yu Yu Lwin2, Myat Kyaw Thu3,
Thandar Soe2, Sai Khun Mine2 & Khine Pwint Nwe1
1 Department of Medical Research
2 Myanmar Medical Association
3National Tuberculosis Programme, Department of Public Health

2. Introduction TB Burden
Myanmar: One of the 30 countries with the highest TB, multidrug-resistant TB (MDR TB) and TB/HIV burden in the world (Global TB report, 2017)
TB incidence: 358/100,000 population
Mortality rate: 51/100,000 population in 2017 (NTP report, 2017)
26% are gap in overall case detection of TB
Case findings still need especially in underserved populations (Global TB report, 2017)

3. Introduction Community based TB Care & ACF
To improve TB control activities in unreached areas, community based TB care activities was done by
National Tuberculosis Programme (NTP)
local non-governmental organizations (NGOs)
Community Support Organizations (CSOs) since 2011
Active case finding (ACF) program enhances the early case detection and prompt treatment (WHO, SEA, 2014)

4. Introduction MMA ACF-TB
Since 2014, in collaborating with National TB Programme (NTP), Myanmar Medical Association (MMA) implemented Active Case Finding TB (ACF TB) project in (12) townships
Yangon, Mandalay, Magway and Ayeyarwaddy Regions
Trained (449) community health volunteers (CHVs)
Township population coverage: 50% in urban areas and 25% in rural areas
Better to include Myanmar map showing 12 townships

5. Introduction Activities of MMA ACF TB project
Selection of CHVs: Local authorities and basic health staff guided by township health department TB focal persons
Main tasks of CHVs
Community awareness rising on TB
Presumptive TB referral, sputum transportation
Directly observed treatment (DOT) supervision
Recording, reporting and participation in coordination meetings and trainings
Supervision by field medical officer and field assistant of MMA ACF TB project
Reporting: Monthly and six monthly

6. Introduction Systematic review showed effectiveness of ACF
(Ho J et al, 2016)
Case referral and proportion of case treated decreasing over time (A recent study assessing ACF of community based TB care programme of NGOs, Htet Myat Win Maung et al, 2017)
Necessary to understand the barriers & strengths to implement community based TB care program successfully

7. Objective
To assess determinants for successful implementation of community based TB care in MMA ACF TB project and its contribution for NTP

8. Methodology Study design A mixed method study Study setting
Township A and Township B which is highest and lowest contribution to NTP in 2016
Study period
January 2018

9. Methodology
Study participants & data collection methods Quantitative method Record review: Secondary data of MMA ACF project in 11 townships (2015 to 2017)
Qualitative methods
In two selected townships (A and B)
Key informant interviews (KIIs): 14 KIIs (lab technician, X ray technician, TB coordinator, local authorities and BHS)
In depth interviews (IDIs): 4 IDIs (field medical officers and field assistants from MMA ACF projects)
Focus group discussions (FGDs):
2FGDs(community health volunteers &
TB patients)
Pair-wised ranking: prioritizing
issues for successful implementation

10. Methodology Data management and analysis Quantitative data
Extracted the aggregated data of six monthly report of MMA ACF TB project in 11 townships in MS Excel format
Aggregated data was analyzed by using SPSS software, described in number and percentage
Qualitative data
All FGDs, KIIs and IDIs were coded manually and matrix analysis was conducted according to main themes and sub-themes
For pair wise ranking during FGDs, issue with the highest count was prioritized as first with getting the group agreement

11. Results MMA ACF case findings in 11 townships (2015 to 2017)
13.6%
5.1%
Number of contacts examined
1593
Positive TB among contacts
104
(5.3%)

12. Results Contribution of MMA ACF activities to NTP in 11 townships
28.4%
29.0%

13. Determinants for successful implementation of ACF
Case detection in study townships from 2015 to 2017
Activities
Township A
Township B
Total suspected TB case referred
2106
1513
All form of TB cases detected
343
212
Bacteriological confirmed TB cases detected
124
172
Contribution of all form of TB to NTP
48.6% (343/705)
15.5% (212/1372)
Contribution of bacteriological confirmed TB to NTP
46.9% (124/264)
29.0% (172/593)

14. Volunteers Patients MMA medical officers Public Health sector
Prioritized issues/determinants for successful implementation of MMA ACF TB project
Volunteers
Patients
MMA medical officers
Public Health sector

15. Prioritized issues/determinants for successful implementation of MMA ACF TB project and reasons
Volunteers
Financial support to patients
"လူနာေတြ ေငြေၾကးအခက္အခဲရွိရင္ ေဆးရုံေဆးခန္း မသြားနုိင္ဘူး။ စီမံခ်က္က သြားစရိတ္လာစရိတ္၊ ဓာတ္မွန္ရုိက္ခ၊ သလိပ္သယ္ပုိ ့ခေတြေပးေတာ့ လူနာေတြအတြက္ အဆင္ေျပတယ္။"
(FGD with volunteers)

16. Volunteer selection and training
Prioritized issues/determinants for successful implementation of MMA ACF TB project
Volunteers
Volunteer selection and training
"လုပ္ငန္းအေပၚ ေစတနာထားသူ၊ တီဘီလူနာမ်ားကုိ ရွာေဖြေပးနုိင္သူ၊
ဆက္ဆံေရးေျပျပစ္တဲ့သူ၊ ငယ္ရြယ္ျပီး ေဝးလံခက္ခဲေသာေနရာေတြမွာ
သြားေရာက္ကာ တီဘီလူနာရွာေပးနုိင္ရင္ ေစတနာ့ဝန္ထမ္းအေနျဖင့္
ေရြးခ်ယ္သင့္တယ္။
ဖ်တ္ဖ်တ္လတ္လတ္၊ သြားနုိင္လာနုိင္ ေျပာရမယ္ဆုိရင္ ရြာမွာလူပ်ဳိလွည့္
နုိင္သလုိ လူမ်ဳိး……."
? WHY reproductive age?
(KII with Lab Technician, Township-A)

17. Prioritized issues/determinants for successful implementation of MMA ACF TB project
Volunteers
Volunteer selection and training
Volunteer selection: Health care volunteers (AMW/CHW) or community member
Health care provider
Pros: Existing skill
Cons: Over-workloads
Community member
Pros: Could assist BHS on the specific job
Cons: less educated, difficulty in providing health care, less respect by community

18. Providing health education Accompanying to health facility
Prioritized issues/determinants for successful implementation of MMA ACF TB project
Patients
Providing health education
Accompanying to health facility
"ကိုယ္မသိတာေတြလည္းသိရတယ္ကိုယ္မသြားတတ္တာေတြလည္းအကုန္
လမ္းညႊန္အစစအရာရာေပါ့ကိုယ့္ဟာနဲ႔ကိုယ္ဆိုဘယ္လိုလုပ္လို႔ဘယ္လိုကိုင္ရ
မွန္းကိုမသိဘူးေတာဆိုေတာ့သိတဲ့အတိုင္းပဲဗဟုသုတေတြကလည္းနည္းတယ္ေလသူတို႔ရွိေတာ့ပိုျပီးေတာ့ျပည့္စံုသြားတာေပါ့” (FGD with patients)
I would suggest to insert two direct quotation and delete the text/bullet points of 2nd and 3rd boxes
“ဆရာမက ေဆးစစ္ဖုိ ့ေဆးေသာက္ဖုိ ့ကူညီေပးတယ္။ ဆရာမေနာက္ကုိ လုိက္သြားရုံပဲ ေရာက္ရင္ေဆးရုံမွာ ထိုင္ေနရုံပဲ။ ဘာမွ လုပ္စရာမလုိဘူး။ အကုန္လုပ္သြားတာ ဆရာမက။ ေန ့လည္စာေတာင္ေကၽြးေသးတယ္။ သြားစရိတ္နွင့္ ဓာတ္မွန္ရုိက္ခေတြလည္းျပန္ေထာက္တယ္။”
(FGD with patients)

19. Prioritized issues for successful implementation of MMA ACF TB project
MMA medical officers
Public Health sector
Collaboration and supervision of public health
sector
Leadership of MMA field medical officers
Recognition of Township Health Department to community health volunteers was essential
if the participation of the township health department was strong, training, TB case finding and referral, monitoring would be better
I would suggest to insert one or two direct quotation and delete the text/bullet points of 2nd and 3rd boxes
Leadership role of field medical officers is the most important factor in
Recruitment and training on volunteers
Quality data management
Supportive management

20. Providing reasonable incentives for volunteers
Other issues/determinants for successful implementation of MMA ACF TB project
Community acceptance on volunteers and their involvement in TB case finding
Providing reasonable incentives for volunteers
Having a strong communication with volunteers and local assigned providers
increasing the manpower of technicians for diagnosis
Close supervision and monitoring to volunteers to reach target for case finding
Need clarification for some facts (providing TB care?, )

21. Barriers for successful implementation of MMA ACF TB project
Recruitment
A difficult job as a few people who interested and applied for volunteer
Less community involvement
Drop out of volunteer
Low incentives
Lack of opportunities than they expected
Health education
Did not respect for volunteers and did not come to the health education session by community
Transportation cost
Travel allowance was not enough as volunteers sending the sputum and taking the patients to hospital by using their motorbikes

22. Suggestions for sustainability of ACF TB project
Having TB staff in township level and RHC level as well
Having a plan to support poor TB patients from village health fund by some authorities
Transportation cost
Other health related cost
Concerning incentives for volunteers
They will not be able to do this work in the long run because they also need to work for their earning.

23. Discussion
High contribution of TB cases to NTP by MMA TB project using trained community volunteers
Nearly one third of all forms and bacteriological confirmed TB case
In our study, the higher in number of referred suspected TB cases by volunteers, significantly higher contribution to NTP
Similar results was reported in studies from Cambodia, India and Ehtiopia (Lorent N et al, 2014; Prasad BM et al, 2016; Arshad A et al, 2014)

24. Determinants for successful implementation of MMA ACF TB project
Financial support to patients
Our findings suggest that in many cases,
Free tuberculosis diagnosis and treatment are not enough
Consider to provide the multitude of costs that TB patients face
Transportation
Lost income , productivity and time
Similar finding was found in Ethiopia studies
(Sagbakken M et al, 2008; Gele AA et al, 2010)

25. Determinants for successful implementation of MMA ACF TB project
Volunteer selection: Community member or AMWs/CHWs
Our finding showed that
Choosing AMWs/CHWs: Good existing skill but over workload
Choosing Community member: difficulty in providing health education, Less respect by community
Other studies pointed out that volunteers were
Lack of knowledge, low incentive and higher drop out
Limited their ability to optimally function (Gilson L et al, 1989)
Community health workers’ services need to be integrated into the health system
Maximize their potential and ensure sustainability
Requires careful assessment of costs and benefits (Gilson L et al, 1989)

26. Determinants for successful implementation of MMA ACF TB project
Providing health education and community acceptance
Our finding also revealed that although health education improved TB awareness in the community, difficulty in providing health education and community less acceptance
One study highlighted that the higher level of education of the volunteers
Increased the incorporation of new knowledge
Assist in advising families and improve health needs of the population (Ferraz L et al, 2005)
Existing volunteer programs designed and decided by local healthcare providers, by not the community itself
Reluctant to accept volunteers by the community
Less community involvement in TB control (O' Brien MJ et al, 2009)
I did not find these facts in your results?

27. Determinants for successful implementation of MMA ACF TB project
Accompanying to health facility and community involvement in TB case finding
One study pointed out that presence of volunteers in the region,
Promoted the articulation between the healthcare services and the community
Identified community problems
Acted in the disease prevention together with the community (Nunes M de O et al, 2002)
I think blue box is findings form other studies, If so, better to show key points (not to elaborate much)

28. Determinants for successful implementation of MMA ACF TB project
Collaboration and supervision of public health sector and Leadership of MMA field medical officers
In our study, not only emphasizing on improving TB case finding, supporting volunteers on their activities as well as close supervision and monitoring were important for successful implementation
One study highlighted that mentorship and supervision have proven to be critical to each volunteer success.
(Ingram M et al, 2008)
To reduce and summarize facts in blue box (eg. The study from ……. Also highlighted mentorship & supervision were critical for success of volunteers activities)

29. Conclusions
Number of TB cases referred and detected by MMA ACF TB project to NTP was high
Not only financial support for patients and volunteers but also volunteer selection and performance were key determinants for successful implementation of ACF TB project.
Human resources at public health sector and community involvement are also essential.

30. Acknowledgements
Our sincere gratitude goes to Director Generals from Department of Medical Research and Department of Public Health, Deputy Director General (Disease Control) and the President from Myanmar Medical Association for their kind approvals to conduct this study.
Special thanks go to Regional Health Director and Regional TB Officer from Yangon and Mandalay Regions, national TB Programme staff, Township Medical Officers, TB coordinators, Basic Health Staff and local authorities from study townships (Kyauktan and Sintkaing).
We are grateful to all TB patients and all participants for sharing their views and experiences with great enthusiasm.
We are grateful to World Health Organization/Tropical Diseases Research (WHO/TDR) regional training Centre, Gadha Madha University, Indonesia and especially Dr. Yodi Mahendradhata and his team for technical support for polishing the IR proposal during IR Workshop.
The study was funded by the Ministry of Health and Sports Implementation Research (IR) grant (Number 216./ ).

31. Thanks you!!!

32. Pair wise ranking financial support role of local authority
CHVs selection
Training
support of THD
role of FMO and FA
training