MDR-TB care: Where do we go when health systems are overburdened?

Alice Tembe, CNS Special Correspondent, Swaziland
In any situation of health crisis, it is normally assumed that care of the sick, especially infectious patients, is designated to clinically trained nurses and doctors in hospital settings. Today, as the world battles with the epidemic of infectious diseases like TB and multidrug-resistant TB (MDR-TB), many settings are faced with limited bed-capacity to hospitalize and care for patients till they can be integrated back into the community.

In particular, high burden countries, which in most cases are low income countries too, have had to transfer care of patients to the community earlier than planned, mostly due to the high prevalence of disease and long terms of treatment.

With HIV/AIDS incidences plateauing, most of the hospital burden is resulting from TB and lifestyle related chronic diseases like cancer, diabetes and mental health disorders. In the 46th Union World Conference on Lung Health held in Cape Town, South Africa during 2-6 December 2015, Swaziland and South Africa shared collaborative partnerships formed with communities to reduce the burden on the healthcare system.

In an estimated population of 1.1 million in the Southern Kingdom of Swaziland, the World Health Organization (WHO) in its 2014 Report estimated TB incidence to be 1382 per 100,000. The National TB Control Programme in Swaziland rated that there is 80% HIV co-infection among the incident TB cases. Unfortunately, cases of MDR-TB are also high, being 8% among previously treated cases. The national bed-capacity to care for these patients in hospital settings is simply not enough. Hence collaborative efforts have to be formed out of necessity.

Dr Samson Haumba, Country Director of University Research Corporation in Swaziland, shared how the country prepared for the collaboration. He noted that in preparing to take patients to the community thought must be given to:-

  • Establish the available capacity of central, regional and health facility staff in the system to deliver and monitor quality MDR-TB services, keeping in mind that the health system is already burdened by other diseases
  • Establish systems that best reach the patient. MDR-TB care services can be integrated with other existing services where they are not offered, like in antiretroviral therapy (ART) centres where HIV positive patients collect medications. Allowing primary care centres to take up care of MDR-TB patients within their constituencies will decongest central care facilities
  • Establish a system that ensures medications and supplies reach all the perimeters in good quality and in time
  • Services need to also target the ‘hard to reach’ or vulnerable populations, who are otherwise not reached by mainstream care facilities. It is also essential to map out the location, size and demography of these populations
  • With every new system or structure there is fear of the unknown. Ensure that the system still embraces all patients without any prejudice or stigma and does not deter access to healthcare
  • Use technology to improve MDR-TB care by creating awareness, and monitoring patients on treatment, while ensuring patient privacy and respect of dignity
  • Form coalitions and partnerships with other healthcare organisations that may also have care facilities, healthcare workers, community health care workers, community based organisations and civil society organisations. Each of these players can bring their unique expertise to solidify and expand care services for MDR-TB outside healthcare settings.
Pastor Nicholas Bhengu, a community leader from Ncaluva Community, KwaZulu Natal in South Africa, shared a case study. He explained that engaging with communities towards care for MDR-TB patients is necessary and welcome.  However, he said that it has to be done with the spirit of ‘ubuntu’ (meaning humanity in Zulu). He explained that while approaching communities one needs to acknowledge their local language and respect the commuity’s tradition and culture; respect the community leaders; and remember that ‘a lack of education is not a lack of life experience.’

In these four key aspects, Pastor Bhengu noted that any patient going to a healthcare facility comes from the community. The patient is a person-- a mother or a wife, or  a daughter to someone in the community first before becoming an MDR-TB patient. This concurs well with Dr Haumba’s explanation that in taking the patient to the community, much reliance and responsibility is put on the community care givers by the healthcare workers as they cannot be present with the patient at all times. Therefore, Dr Haumba noted that it is essential to invest in the training of community care givers to build their capacity in caring for MDR-TB patients. He noted, that the community health care workers need to understand the multiple drugs available, the side effects associated with the treatment, basic home remedies, importance of recording and reporting patient care and services available to them for reference when need arises.

Alice Tembe, CNS Special Correspondent, Swaziland
16 December 2015 
(Alice Tembe is providing thematic coverage from 46th Union World Conference on Lung Health in Cape Town, South Africa, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @Tembe3)