|
| Steps involved |
Factors/categories to consider |
Actions to consider |
Chapter 1 |
| Identification of the poor and vulnerable groups in the country/region served by the national TB control programme |
Groups and situations including:
- unemployed
- homeless people
- gender-related discrimination
- marginalized ethnic groups
- people in remote locations
- urban poor
- special groups (see Chapter 4)
|
Establish the profile of poor and vulnerable groups in the country/region using:
- government (or other) data on the prevalence and distribution of poverty and social vulnerability and on poverty-reduction plans
- information on which types of health care providers are used by poor and vulnerable groups
- locally conducted surveys on the socio-economic status of TB patients and poverty related disparities
- information on any adaptations already made in DOTS delivery to serve poor and vulnerable groups in the country
|
Chapter 2 |
| Identification of the barriers to accessing TB services faced by the poor and vulnerable groups in the country/region |
Economic barriers:
- complexity of pathway to access care
- costs of care-seeking
Geographical barriers:
- distance from TB services
Social and cultural barriers:
- stigma
- fear of losing work
- lack of knowledge of TB and services
- gender-related factors
- lack of health system responsiveness
Health system barriers:
- staff attitudes to poor patients
- lack of effective peripheral services
|
Assess economic barriers by examining:
- whether the organization of the TB services simplifies the health care pathway; whether diagnostic and treatment services for TB are well integrated in general primary care facilities;
- whether treatment observation requires patients to make multiple visits;
- which services provided by the national TB control programme patients are required to pay for
Assess geographical barriers by identifying areas where patients have to travel long distances or over difficult terrain to reach TB services
Assess social and cultural barriers by:
- Identifying areas and population groups in which TB services are underutilized;
- identifying and analysing the principal barriers to accessing TB services which affect poor and vulnerable groups
Assess health system barriers by:
- investigating staff attitudes towards poor patients;
- assessing whether decentralization leads to strengthening of TB services at primary care level
|
Chapter 3 |
| Identification of potential actions to overcome the barriers to access |
- Adapting the national TB control programme plan to address the needs of poor and vulnerable groups, including specific measures to address economic, geographical, social/cultural and health system barriers.
- Deciding country-specific priorities for pro-poor interventions, taking account of needs, resources, feasibility, and effectiveness of the measures envisaged
|
Address economic barriers by:
- integrating TB services within primary care provision; encouraging pro-poor PPM DOTS; promoting TB control in workplaces; improving the coverage of smear microscopy networks; avoiding user-fees; provision of free smear microscopy and treatment; providing food; arranging social security
Address geographical barriers by:
- extending diagnostic and treatment services to remote regions; bringing poor patients from remote areas to TB services; providing free transport; developing appropriate community-based TB care models
Address social and cultural barriers by:
- engaging former TB patients and TB support groups to advocate for TB services and encourage community mobilization; ensuring that health staff attitudes and behaviour do not reinforce stigma; advocating for legal frameworks to protect against loss of employment because of TB; ensuring that the TB health promotion plan takes account of the specific needs of poor and vulnerable groups; ensuring that gender-related needs are addressed in TB control activities; providing psychological support in the community; considering cooperation with traditional health providers
Address health system barriers by:
- adapting health care facility schedules; developing communication skills among health care staff and discouraging discrimination against poor patients; using total quality management to ensure that services remain responsive to the needs of the poor; encouraging community mobilization and demand for TB services among the poor; engaging in health service decentralization to ensure capacity strengthening in less well served areas and TB control as a district-level priority
|
Chapter 4 |
| Situations and population groups requiring special consideration |
Migrant populations:
- refugee communities, asylum seekers, economic migrants and displaced populations, cross-border populations Pockets of deprivation in wealthier countries:
- ethnic minorities, homeless people, injecting drug users, prison populations, any other deprived population groups in the country
|
- Define the special situations and vulnerable groups in the country/region
- Identify these groups and their locations
- Assess the problems they face in accessing TB services
- Establish priorities for action based on needs, feasibility, available resources, and effectiveness of the interventions
- Examine current services available to the priority groups and identify current health care providers
- Define strategies and measures to improve access to TB services by the poor and vulnerable groups
- Build partnerships with current providers of services for the vulnerable groups
- Plan a phased implementation of the measures selected
|
Chapter 5 |
| Harnessing resources for pro-poor TB services |
Migrant populations:
- Available strategies to engage in broad initiatives to improve access to health services
- Sources of funding for improvement of health outcomes
- Institutions offering additional financial and other resources
- Human resources to expand the public and private sector involvement in TB services
- Technologies to enhance efficiency and effectiveness of TB services
|
- Identify any new partnerships, financing mechanisms, human resources and tools or technologies that might be available
- Assess the feasibility of mobilizing and maintaining these resources
- Prioritize which existing mechanisms might offer the greatest benefits in the short and medium term
- Identify new resources to target for mobilization within the next six months, and within the next two years
- Identify the three most influential external and local stakeholders who could help to address priority needs
|
Chapter 6 |
| Assessment of the pro-poor performance of the national TB control programme and the impact of pro-poor measures |
Migrant populations:
- Targets for TB control in the poor
- Distribution of TB in the population
- Beneficiaries of DOTS services
- Poverty-related disparities
- Assessment of impact of pro-poor measures
|
Facilitate monitoring of poverty-related inequalities and the impact of pro-poor interventions by:
- Harnessing the human and other resources required for equity monitoring through alliances with partners
- Considering the inclusion of socio-economic variables in routine data collection and analysis;
- Ensuring that TB-related questions are included in DHS, LSMS and other household surveys
- Ensuring that socio-economic questions are included in TB prevalence surveys
- Conducting periodic studies of care-seeking, diagnostic delay and use of DOTS in health facilities, with linked socioeconomic data
- Conducting qualitative assessments among community members and TB patients about who benefits from TB services and who does not
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