Globally 1 in 3 people are infected with tuberculosis (TB) of which 1 in 10 will go on to develop TB disease during their lifetime. In 2013, there were 9 million new cases but consistently 3 million people were not diagnosed, treated, or officially registered by national TB programmes (NTPs). Many of those missed by the NTPs will die or follow ineffective treatments and most will continue to infect others. Among those missed are those most vulnerable to falling ill with TB including the very poor and/or malnourished or undernourished people, people living with HIV/AIDS, children and women, migrants, prisoners, refugees and internally displaced persons, miners, the elderly, ethnic minorities, indigenous populations, drug users and homeless persons. Every year, on the 24th March, the world marks World TB Day (#WTBD2015) to mobilize political and social commitment for further progress towards eliminating TB. This year the Stop TB Partnership continues for a second year its campaign to reach the 3 million people missed (#ReachTreatCureEveryone).
To reach, treat and cure everyone, there is a critical need to address weaknesses in the countries’ health systems. This includes reaching out to populations that struggle to access health services. One successful example of an innovative community-based approach was conducted in Ethiopia; a country in which over 80% of the population live in rural areas and most TB diagnostic and treatment centres are located in urban areas. Through the engagement of community health extension workers (CHEWs), the non-governmental organisation REACH Ethiopia is aiming to bring TB diagnosis, treatment and information about TB to rural areas that previously had limited access to healthcare services. CHEWs are salaried females trained for one year by the Health Service Extension Program, who come from and live within the communities they serve and implement 16 basic health packages in the community. REACH Ethiopia engaged with the CHEWs to train them to identify residents with chronic cough and facilitate the examination of their sputum to increase access to diagnosis. Residents who are shown to have TB are offered treatment at home, or at the village health post, ensuring that the whole population has access to diagnosis and treatment. This simple approach doubled TB notification in a population of 3 million and increased the treatment success rate to 93%. The project, funded by the Stop TB Partnership’s TB REACH initiative and implemented by REACH Ethiopia and the Liverpool School of Tropical Medicine, in collaboration with the Southern Region Health Bureau and the Global Fund, has engaged with some 1100 CHEWs, who are supported by a team of motorbike riders, who play a supervisory role, to create a bridge between remote rural communities and far away healthcare centres. The results from the project, published in PLOS One, show that over 5000 people with infectious TB were found in the 15 months of implementation between October 2010 and December 2011 compared to the previous 15 months of only 2500 people with TB being reported to the TB programme. The project was of particular benefit to women and children, who formed a great proportion of the people provided with TB care compared to control areas. Embedding services within communities was found to be valued by poor and rural communities with limited access to health facilities (Tulloch et al. BMC Public Health). The project is highly praised by the community and the ministry of health and its success was recognised with the awarding of the prestigious Kochon Prize at the 45th Union World Conference on Lung Health in 2014.
In a similar study, soon to be published, CHEWs engaged with community leaders (the Chief of Chiefs, ethnic chiefs, town criers, the women development army and youth organisations) to alert communities living in the slums around Abuja in Nigeria, areas which facilitate TB transmission and have very few diagnostic and treatment facilities, of medical teams systematically visiting households to invite ill people to provide specimens for examination and to help identify as many symptomatic people in their neighbourhood.
These examples of community involvement supports the recent Cape Town Statement from the Global Symposium on Health Systems Research which acknowledges that “Many crucial drivers of health system change lie outside of the traditional boundaries of the health system; social mobilization and intersectoral action are critical for re-orienting health systems to be more people-centred. Community health workers can play an important linking role in enabling inclusive and representative community participation.” We hope the importance of mobilising CHEWs for TB control is recognised in the new Global Plan to Stop TB 2016 – 2020. This plan will outline what will be required to reach the goals set in the post-2015 Global TB Strategy by the World Health Organization that aims to eliminate TB as a global epidemic by 2035.
By Kerry A. Millington, Programme Manager, HEART and Liverpool School of Tropical Medicine and Luis E. Cuevas, Professor of International Public Health and Epidemiology, Liverpool School of Tropical Medicine