Models of good cooperation between Red Cross of Serbia

and Health Care system in TB control

Marija ČukićProject Coordinator TB Control in Serbia GFATM grant Rnd 9

Red Cross of SerbiaSarajevo 28/29.05.2015.

Legal bases

• International Movement of Red Cross and Red Crescent Resolution No 2 – Red Cross is humanitarian, voluntary independent organisation auxilliary the Government

• Law on Red Cross of Serbia (Official Gazzette 107/05) – article 9. bulletin 7

„in collaboration with health institutions in activities related to the promotion of health and prevention of diseases of social and medical importance.”– article 13.

“The Red Cross of Serbia shall secure funds from the budget of the Republic of Serbia and the budgets of the provincial and local authorities for exercising its public powers referred to under articles 6 and 7 of the present Law and implementing programs referred to under article 9, paragraph 7 of the present Law”

TB Control

Title of the project :“To reduce the burden of tuberculosis in the Republic of Serbia through scaling up MDR-TB interventions, strengthening the DOTS implementation, TB-HIV collaborative activities and strengthening TB control in vulnerable populations”

GA with TGF 1.07.2010-30.06.2015.

TB Control project

• Red Cross of Serbia is a second Primary Recipient for the GF grant besides Ministry of Health RS.

There were 4 main objectives of the Project:• Strengthening and expansion of the access to

treatment and proper management for drug resistant TB cases – MDR and XDR TB

• Ensuring that the basic DOTS package is maintained and further strengthened

• Addressing TB control in vulnerable populations• Addressing the TB/HIV co-infection

5 key indicators:

Number of people trained in TB and TB/HIV issues, including the screening of vulnerable groups for TB

Percentage of contacts of the Roma smear-positive TB patients referred to TB Unit and examined for TB out of all contacts of smear positive Roma identified during the period covered.

Number and percentage of kitchen/meal users screened for TB Number of female sex workers screened for TB Number of Injecting drug users regularly benefiting from needle exchange

programs screened for TB

First three indicators are covered by the Red Cross network Ssecond two are covered by NGO network in 4 big cities in Serbia

16 sub recipients – 9 + 7

At the beggining...

• Lack of trust of HS in civil society involvment• No confidence to the system itself• Benefiriaries with specific vulnerabilities SK,

IDU,SW • No strong link between RC and NGO sector• No link between the field workers- Roma health

mediators, Red Cross, NGOs• No clue how to “glue” it

Good cooperation model No 1- active case finding

TB unit- visiting nurse -info on TB patient-

Red Cross coordinator

Meeting and steps to be taken: all stakeholders/Roma health mediators, TB unit

representatives, Red Cross coordinator/local Red Cross, visiting nurse

Outreach work- contact tracing ( first visit- up to 17 visits!)

Medical check of contacts:all stakeholders- Red Cross , Roma Health

Mediator

No sense of responsibility – numerous visits to the slam and TB units

Lack of trust of parents- ( PPD test-Mantou test)

Administration silence

Tracing contacts and referral success

Contact tracing of TB smear positive Roma person *Follow up of the success in tracing contacts per year

2011 2012 2013

Index persons 10 4 1

Identified and medically checked index person contacts 78%

105/13597%

32/3398%

42/43

Contacts- children under 18 3 15 42TB confirmed and treated 3 15 0

No of motivation DOT parcels** 11 52 35

* Contact tracing is performed only if requested by the TB unit**18 places in Serbia

Referral success of SW and IDU Active case finding 2011. 2012. 2013. 2014.

SW( % medically checked out of referred)

0% 8% 27% 59%

No of referred VS No of medically checked

0/130 9/111 13/48 51/87

IDU ( % medically checked out of referred)

6% 53% 88% 84%

No of referred VS No of medically checked

6/104 28/52 68/77 82/98

ESTABLISHING DUTIES OF TB EXPERTS INNGO DROP IN CENTERS

Challenges- SW and IDU

• Legal boundaries – sex work and injecting drugs is not legal

• No personal documents• Fear to be exposed,• Out of personal time control,• Seeking for help only in

emergency,• No habit of “waiting in the

queue”

Challenges for TB experts

• Change of the working environment

• No white uniform- “Am I professional enough?”

• Need additional skills • Understanding the specifics

of the beneficiary profile• Withholding from delivering

the “recipes” how to live a life

THE STATE AND HEALTHCARE SYSTEM HAVE RESPONSIBILITY

To enable the most efficient access and interventions for all patients who suffer from serious diseases. For this approach to be successful, health workers within the healthcare system must provide services in compliance with patients’ needs and wishes. If a large number of patients fail to complete the treatment, the healthcare system has not worked well.

In the name of public health, PATIENTS MUST be treated. The law regulates this imperative. It is believed that these patients do not know, understand and care of the importance to complete the treatment. For these reasons, the recommendation is that there are sanctions if the patients do not comply with doctor's recommendations apart from education, motivation and monitoring.

Program that is not patient-oriented

Patient-oriented program

Responsibilities?

Good cooperation model No 2- establishing duties of TB experts in NGO drop in centers

• From 2012. in 3 and from 2013. in 4 NGOs – Belgrade, Novi Sad, Nis

• First contact between SW or IDU with Health System takes place in the familiar environment with no fear whatsoever.

• Red Cross of Serbia established cooperation with 3 institutions for lung diseases from Belgrade, Vojvodina and Nis

• 75 places/Red Cross organizations in Serbia• Different vulnerability than SW and IDU• High, often non realistic expectations from the

state and community, Red Cross…• No general determinant for poverty –

difference in SK beneficiary profile 10 years before and today

Active case finding among SK beneficiaries

Referral success of SK

Active case finding among SK beneficiaries

2011. 2012. 2013. 2014.

SK –( % medically checked out of referred) 20% 38% 70% 92%

No of referred VS No of medically checked

239/1.177 287/752 265/382 315/343

• Beneficiary has TB symptoms but no health card

• Beneficiary has expectations to receive some goods in exchange for information

• Beneficiary deliberately lies on TB symptoms expecting reword if respond is “yes”

• Lack of functional literacy and administration rules ad regulations

• “Besides feeding us you take care of our health”

• “You are so kind, nobody wants to see or hear us”

• “You helped me reach the doctor- it is not TB but now I am taking my therapy”

Experience with SK beneficiaries

• Red Cross network used good cooperation with local TB units

• Building trust between beneficiaries and Red Cross staff/volunteers

• Different stakeholders involvement • Holistic approach to the person• Different sustainable incentive provision

Good cooperation model No 3- creation of link between stakeholders on the local level

TB in vulnerable populations

Coverage ( No of confirmed TB VS No beneficiaries)

2011. 2012. 2013. 2014.

SK0/23.049 90*/21.313 8/19.665 5/20.278

SW0/659 0/496 0/527 1/506

IDU 0/337 1/273 0/299 0/310

Contacts 3/135 15/33 0/43 n/a

Sustainability steps

• Advocating for establishing Council for health with Red Cross members in it and TB high on the priority list on the local level,

• Negotiation with Republic Fund for Health Insurance to recognize the duties of TB experts in drop in centers on the service list,

• Advocating for direct referral of vulnerable population to the local TB units for diagnostics on TB.