National Tuberculosis National Tuberculosis Program Program Lao PDRLao PDR

Action PlanAction Plan

General informationGeneral information▫▫ Lao PDR is a land locked country Lao PDR is a land locked country ▫▫ Surface : 236,800 sq.kmSurface : 236,800 sq.km▫▫ Population: 5,6 millionPopulation: 5,6 million

(22.3 (22.3 inhinh/sq.km)/sq.km)▫▫ 2/3 of the terrain is mountainous 2/3 of the terrain is mountainous ▫▫ The major occupation of people is The major occupation of people is

agricultureagriculture▫▫ 18 provinces, 142 districts18 provinces, 142 districts▫▫ Health status : Health status :

3 3 Central Hosp.Central Hosp.4 4 Regional Hosp.Regional Hosp.18 18 Provincial Hosp.Provincial Hosp.142 Districts Hosp.142 Districts Hosp.703 703 HCsHCs

Epidemiology of TBEpidemiology of TB

TB is a major public health problemTB is a major public health problemARI : 1.2 % ( Tuberculin survey in 1995 ) ARI : 1.2 % ( Tuberculin survey in 1995 ) 180 new TB cases / 100,000 est.incidence180 new TB cases / 100,000 est.incidenceAbout 72 new TB cases per year of them About 72 new TB cases per year of them being infectious ( 72 new S+ / 100,000 )being infectious ( 72 new S+ / 100,000 )

DOTS Coverage 1995DOTS Coverage 1995--20052005

0

20

40

60

80

100

120

140

160

1995 1997 1999 2001 2003 2005

Province

District

Healthcenter

Case detection of new smear + ( 1995 Case detection of new smear + ( 1995 -- 2005 )2005 )

0

500

1000

1500

2000

2500

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 ( 3Q.)

0%

10%

20%

30%

40%

50%

60%

No. ofNS+

CDRNS+

Treatment success rate of new s+ (1995Treatment success rate of new s+ (1995--2005)2005)19951995 19961996 19971997 19981998 19991999 20002000 20012001 20022002 20032003

CuredCured( % )( % )

62.462.4 65.565.5 7474 73.573.5 7979 7272 69.569.5 6767 7070

CompletedCompleted( % )( % )

7.67.6 6.56.5 77 8.58.5 44 88 10.510.5 1111 99

FailureFailure( % )( % )

1.51.5 0.40.4 11 0.30.3 0.50.5 0.30.3 0.70.7 0.20.2 0.50.5

DiedDied( % )( % )

66 88 66 77 77 77 88 77 88

DefaultedDefaulted( % )( % )

1919 1010 99 1010 77 99 99 1111 99

TransferTransferOut ( % )Out ( % )

3.53.5 9.69.6 33 0.70.7 2.52.5 1.71.7 2.32.3 3.83.8 3.53.5

Treatment success rate of new smear + 1995Treatment success rate of new smear + 1995--20052005

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1996 1997 1998 1999 2000 2001 2002 2003

SuccessrateDied rate

Defaulted rate

Stake holder analysisStake holder analysis

BeneficiariesBeneficiaries PotentialPotentialopponentsopponents

ImplementingImplementingagenciesagencies

Decision Decision --makersmakers

Funding Funding agenciesagencies

. . Lao peopleLao people

. Patients. Patients

. Villagers. Villagers

. Health . Health workersworkers

. TB staff. TB staff

. Program. Programmanagermanager

. . ShamansShamans . . Gov. of LaoGov. of LaoPDRPDR

. MOH. MOH

..ProvProv. H. Off. H. Off

. Dist. H. Off. Dist. H. Off

. H.Ws. H.Ws

. . VHVsVHVs

. . TB treatmentTB treatmentsupporterssupporters

. . Gov. of LaoGov. of LaoPDRPDR

. MOH. MOH

..ProvProv. H. Off. H. Off

. Dist. H. Off. Dist. H. Off

. . Gov. of LaoGov. of LaoPDRPDR

. GF. GF

. DFB. DFB

. WHO. WHO

TB burden in Lao PDR is increased

Annual risk of TB infectionis increased

No of TB morbidity is increased

Low rate of treatment success of smear + TB

High defaulted rate (1) High death rate (2)Laboratory activities are Not functioning properly

in some area (3)

( Core problem )

( Direct effects )

( Direct causes )

● Problem anlysis

High defaulted rate (1)● Problem anlysis(1)

Poor defaulter tracing mechanism Case holding activities are not done properly in some area

Insufficient counselingskills for health workers

Insufficient perdiems for health workers to trace defaultedpatients

Lack of transport in

some Provincial & Disricts

DOTS units

Unqua-lified

TB staffat some

level

Insufficienttraining

for newly hired

TB staff

Work over

Loaded for

TB staff

● Problem analysis (2)High death rate (2)

Patientsmisunderstand

the length ofTB treatment

Poor knowledge

of TB for TB patients

HWs did not Give H.E on TB

Sufficiently toPatients

TB / HIV cases are increased

Patient’sdelay on

treatment

Patients are not

aware of TB center

service

pilot area is limited

● Problem analysis(3)

Laboratory activities are not func-tioning properly in some area (3)

UnqualifiedTB laboratory

staffat some levels

InsufficientTraining for Newly hired

TB laboratorystaff

Lack of equip-ment atsomelevels

TB burden in Lao PDR is decreased

Annual risk of TB infectionis decreased

No of TB morbidity is decreased

High rate of treatment success of smear + TB

Low defaulted rate (1) Low died rate (2) Laboratory activities are improved (3)

( Core objective )

( Direct ends )

( Direct means )

● Objective analysis

Low defaulted rate (1)

defaulter tracing mechanism are improved

Case holding activities are improved

sufficient counselingskills for health workers

Providesufficient perdiems for health workers to trace defaultedpatients

Provide transport toProvincial & Disricts

DOTS unitswhere lacking

Qualifica-tion of

TB staffare

improved

Providesufficienttraining

for newly hired

TB staff

Work over Loaded

for TB staffis reduced

( Direct means )

● Objective analysis (1)

● Objective analysis (2)Low death rate (2)

Patientsunderstandthe length of

TB treatment

knowledgeof TB for

TB patientsIs improved

HWs giveH.E on TB

sufficiently toTB patients

TB / HIV cases are decreased

Patientsstart the

treatmenton time

Patients are

aware of TB center

service

ExpandTB / HIV

pilot projectto otherarea

( Direct means )

● Objective analysis (3)

Laboratory activities are improved (3)

The qualificationof TB laboratory

staffare improved

Providesufficient

training for newly hired

TB laboratorystaff

Provide equipment

to somelevelswherelacking

( Direct means )

Low defaulted rate (1)

defaulter tracing mechanism are improved

Case holding activities are improved

sufficient counselingskills for health workers

Providesufficient perdiems for health workers to trace defaultedpatients

Provide transport toProvincial & Disricts

DOTS unitswhere lacking

Qualifica-tion of

TB staffare

improved

Providesufficienttraining

for newly hired

TB staff

Work over Loaded

for TB staffis reduced

( Direct means )● Decreasing defaulted rate approach

Low death rate (2)

Patientsunderstandthe length of

TB treatment

knowledgeof TB for

TB patientsIs improved

HWs giveH.E on TB

sufficiently toTB patients

TB / HIV cases are decreased

Patientsstart the

treatmenton time

Patients are

aware of TB center

service

ExpandTB / HIV

pilot projectto otherarea

( Direct means )

● Decreasing death rate approach

Laboratory activities are improved (3)

The qualificationof TB laboratory

staffare improved

Providesufficient

training for newly hired

TB laboratorystaff

Provide equipment

to somelevelswherelacking

( Direct means )

● Improving laboratory activties approach

Project selectionProject selectionDecreasing defaulted Decreasing defaulted rate approachrate approach

Decreasing death rate Decreasing death rate approachapproach

Improving laboratory Improving laboratory activtiesactivties approachapproach

Target groupTarget group TB patients TB patients Project managerProject managerProject coordinatorProject coordinatorNTC staff, NTC staff, PTCsPTCs, , DTMsDTMsVHVsVHVs

TB patients TB patients Project managerProject managerProject coordinatorProject coordinatorNTC staff, NTC staff, PTCsPTCs, , DTMsDTMs VHVsVHVs

TB patients TB patients Project managerProject managerProject coordinatorProject coordinatorNTC lab.staff, NTC lab.staff, provprov.hosp. &.hosp. &Distr.hosp. lab.staff Distr.hosp. lab.staff

Related agenciesRelated agencies Capable of implementationCapable of implementationHighHigh

Capable of implementationCapable of implementationDifficultDifficult

Capable of implementationCapable of implementationHighHigh

inputsinputs Cost of : Stationeries, Cost of : Stationeries, printing existing printing existing IECmaterialIECmaterial

(poster,brochure) (poster,brochure) Check list quest. Check list quest. new cars , new motorbikesnew cars , new motorbikes

Large amountLarge amount

Cost of : Stationeries, Cost of : Stationeries, printing existing printing existing IECmaterialIECmaterial

(poster,brochure) (poster,brochure) Cost for expanding TB/HIV pilot Cost for expanding TB/HIV pilot project to other areaproject to other area

Large amountLarge amount

Cost of : Stationeries ,Cost of : Stationeries ,printing existing printing existing IECmaterialIECmaterial

(poster,brochure) (poster,brochure) new new microscopiesmicroscopies

Large amountLarge amount

Policy prioritiesPolicy priorities HighHigh LowLow HighHigh

FeasibilityFeasibility . . Recipient is technically Recipient is technically competentcompetent..SignifiantSignifiant inputs required inputs required but no more than the limitbut no more than the limitHighHigh

. . Recipient is technically Recipient is technically competentcompetent..SignifiantSignifiant inputs required inputs required

LowLow

. . Recipient is technically Recipient is technically competentcompetent..SignifiantSignifiant inputs required inputs required

HighHigh

sustainabilitysustainability No problem in training No problem in training DTMsDTMs and and VHVs VHVs

HighHigh LowLow HighHigh

Action PlanAction Plan

►► Project nameProject name : : Increase the rate of treatment success Increase the rate of treatment success of new s+ TBof new s+ TB

►► Target areaTarget area :: Lao PDRLao PDR►► Target groupTarget group : : TB patients TB patients

Project managerProject managerProject coordinatorProject coordinatorNTC staff NTC staff PTCs PTCs DTMs DTMs VHVs VHVs

►► DurationDuration : : Jan. 1, 2007 Jan. 1, 2007 –– Dec. 31, 2009Dec. 31, 2009

►► Overall GoalOverall Goal

Overall GoalOverall GoalTB burden in Lao PDR is decreasedTB burden in Lao PDR is decreasedVerifiable indicatorARI of TB is reduced from 1.2% to 0.8% by the end of 2009Means of verificationMeans of verificationResult of tuberculin survey .Result of tuberculin survey .Important assumptionImportant assumptionThe TB control policy of the MOH remains The TB control policy of the MOH remains unchangedunchanged

►► Project purposeProject purpose

Project purposeProject purposeDefaulted rate of of new s+ TB is decreasedDefaulted rate of of new s+ TB is decreasedVerifiable indicatorDefaulted rate of new s+ TB is decreased from 9% to 3% by the end of 2009Means of verificationMeans of verificationquarterly performance cohort reportquarterly performance cohort reportImportant assumptionImportant assumptionThe political commitment at provincial and district The political commitment at provincial and district level continueslevel continues

►► OutputsOutputs

Defaulter tracing mechanism is Defaulter tracing mechanism is improvedimprovedCase holding activities are improvedCase holding activities are improved

►►Output(1):Output(1): Defaulter tracing mechanism is improvedDefaulter tracing mechanism is improved

Verifiable indicatorPercentage of defaulted cases traced by HWs is increased from 40% to 80% by the end of 2009Means of verificationMeans of verificationinterview result from the supervision visits interview result from the supervision visits Important assumptionImportant assumptionThe donor support the project sufficiently The donor support the project sufficiently

►►Output(2): Case holding activities are improved Output(2): Case holding activities are improved

Verifiable indicatorPercentage of district performing adequate monitoring is increased from 80% to 100% by the end of 2009Means of verificationMeans of verificationdata from statistic checking system data from statistic checking system

Output(1): Output(1): Defaulter tracing mechanism is improvedDefaulter tracing mechanism is improved

●● ActivitiesActivities1. Provide sufficient counseling skills for 1. Provide sufficient counseling skills for DTMs DTMs

and and VHVsVHVs2. Provide sufficient 2. Provide sufficient perdiemsperdiems for for DTMsDTMs and and VHVs VHVs

to trace defaulter pts to trace defaulter pts 3. Provide transport to provincial and districts3. Provide transport to provincial and districts

DOTS units where lacking DOTS units where lacking 4. Conducting interview to identify defaulted 4. Conducting interview to identify defaulted

tracing situation during the supervision visitstracing situation during the supervision visits

Output(2): Output(2): Case holding activities are improved Case holding activities are improved

●● ActivitiesActivities1.1. Provide training courses to Provide training courses to DTMsDTMs and and VHVsVHVs to to

improve their qualification.improve their qualification.2. Discussion and advice given to 2. Discussion and advice given to PTCsPTCs regarding regarding

the work sharing to reduce the work overloaded the work sharing to reduce the work overloaded for for DTMsDTMs and Village Health Volunteers .and Village Health Volunteers .

Output(1): Output(1): Defaulter tracing mechanism is improvedDefaulter tracing mechanism is improvedAct.(1): Act.(1): Provide sufficient counseling skills for Provide sufficient counseling skills for

DTMsDTMs and and VHVsVHVs

1.1 1.1 NTC staff and NTC staff and PTCsPTCs provide training coursesprovide training coursesto to DTMsDTMs

1.2 1.2 PTCs PTCs provide training courses to provide training courses to VHVs VHVs 1.3 NTC staff conduct 1.3 NTC staff conduct supervsuperv. visits to evaluate . visits to evaluate

the performance of the performance of DTMsDTMs and and VHVsVHVs after after giving training courses giving training courses

Output(1): Output(1): Defaulter tracing mechanism is improvedDefaulter tracing mechanism is improvedAct.(2): Act.(2): Provide sufficient Provide sufficient perdiemsperdiems for for DTMs DTMs

and and VHVsVHVs to trace defaulter patientsto trace defaulter patients

2.1 2.1 NTC provide NTC provide perdiemsperdiems to District DOTS to District DOTS units for tracing defaulter pts .units for tracing defaulter pts .

2.2.2 NTC provide 2 NTC provide perdiemsperdiems to HC DOTS to HC DOTS units for tracing defaulter pats .units for tracing defaulter pats .

Output(1): Output(1): Defaulter tracing mechanism is improvedDefaulter tracing mechanism is improvedAct.(3): Act.(3): Provide transport to provincial and Provide transport to provincial and

districts DOTS units where lackingdistricts DOTS units where lacking

3.1 3.1 NTC provide 4 cars ( 4 x 4 pick NTC provide 4 cars ( 4 x 4 pick -- up ) up ) for 4 provinces where lacking for 4 provinces where lacking

3.23.2 NTC provide 60 motorbikes for NTC provide 60 motorbikes for 60 districts DOTS units where lacking60 districts DOTS units where lacking

Output(1): Output(1): Defaulter tracing mechanism is improvedDefaulter tracing mechanism is improvedAct.(4): Act.(4): Conducting interview to identify defaultedConducting interview to identify defaulted

tracing situation during the super. visitstracing situation during the super. visits

4.1 4.1 PTCsPTCs interview interview DTMsDTMs about the proportion of about the proportion of defaulted cases traced by defaulted cases traced by HWsHWs in the in the dist.hosp. during the super. visits dist.hosp. during the super. visits

4.2 4.2 DTMsDTMs interview interview VHVsVHVs about the proportion of about the proportion of defaulted cases traced by defaulted cases traced by HWsHWs in the in the HCs HCs during the super. visits during the super. visits

Output(2): Output(2): Case holding activities are improvedCase holding activities are improvedAct.(1):Act.(1): Provide training courses to Provide training courses to DTMs DTMs andand

VHVsVHVs to improve their qualificationto improve their qualification

1.1 1.1 NTC staff and NTC staff and PTCs PTCs provide training provide training courses to courses to DTMsDTMs ..

1.21.2 PTCs PTCs conduct training courses to conduct training courses to VHVsVHVs ..1.31.3 NTC staff conduct NTC staff conduct supervsuperv. visits to evaluate. visits to evaluate

the performance of the performance of DTMsDTMs and and VHVs VHVs after after giving training courses .giving training courses .

Output(2): Output(2): Case hold. activities are improvedCase hold. activities are improvedAct.(2): Act.(2): Discus. and advice given to Discus. and advice given to PTCs PTCs

regarding the work sharing to reduce regarding the work sharing to reduce work overloaded for work overloaded for DTMsDTMs and and VHVsVHVs

2.1 2.1 PTCsPTCs interview each staff about the work overinterview each staff about the work overloaded in the distr. Hosp. to distribute the work loaded in the distr. Hosp. to distribute the work for for DTMsDTMs to reduce the work overloaded to reduce the work overloaded

2.22.2 DTMsDTMs interview each staff about the work overinterview each staff about the work overloaded in the loaded in the hcshcs to distribute the work for to distribute the work for VHVsVHVs to reduce the work overloadedto reduce the work overloaded

InputsInputs►► PersonnePersonnel :l :

Project managerProject managerProject coordinatorProject coordinatorNTC staff NTC staff PTCs PTCs DTMs DTMs VHVs VHVs

►► EquipmentEquipment ::Stationeries for trainer and traineesStationeries for trainer and traineesIEC material ( poster , brochure ) IEC material ( poster , brochure ) Check list for questionnaire to interviewCheck list for questionnaire to interview4 cars ( 4 x 4 pick4 cars ( 4 x 4 pick--up ) for 4 provinces where lackingup ) for 4 provinces where lacking60 motorbikes for 60 districts DOTS units where 60 motorbikes for 60 districts DOTS units where lacking ( 1 motorbike for 1 districts ) . lacking ( 1 motorbike for 1 districts ) .

►► DonorDonor : : Global FundGlobal FundDFBDFB

►► Important assumptionImportant assumption

Trained Trained HWsHWs continue to work for their continue to work for their communitiescommunitiesThe collaboration and support from several The collaboration and support from several concerned such as :concerned such as :NTP, PH Depart. , DH Office, staff, fund continuesNTP, PH Depart. , DH Office, staff, fund continues

►► PreconditionPreconditionPartner agency does not oppose the projectPartner agency does not oppose the project