Evaluating HAMNASA’s Tuberculosis Screening Services and Patient Management by District Assistants in Dili, Timor-Leste

Abstract

Introduction: The primary focus of the Mother and Child Tuberculosis (TB) and Nutrition Program is on screening interventions utilizing a ‘One Stop’ TB mobile diagnostic van provided by the Ministry of Health (MoH) with support from The World Health Organization (WHO)and the Global Fund Timor-Leste. The program aims to achieve a rapid decline in TB incidence, mortality, and morbidity, reducing the incidence of TB by 50% by 2025 and 90% by 2035. This pilot project involves conducting community TB screening with a mobile van equipped with digital X-ray, AI analysis, and rapid molecular tests at four Community Health Centers (CHCs). The project's effectiveness will be assessed to determine if it should be implemented in other municipalities in the future.Methods: The study utilizes a mixed-method approach, combining quantitative and qualitative data collection in an exploratory sequential design. The evaluation aims to identify facilitators and barriers recognized by HAMNASA in providing TB screening at four community health centers and their areas of coverage, as well as the challenges faced by district tuberculosis assistants in managing TB patients at those centers. Focus group discussions included all HAMNASA mobile team providers—a doctor, nurse, laboratory analysts, and radiographer—who are tasked with implementing the Maternal and Infant Tuberculosis and Nutrition Program. Additionally, key informant interviews were conducted with key stakeholders, including the TB municipal coordinator from each of the four healthcare centers in Dili, HAMNASA’s executive director, and the national TB manager. In addition, quantitative data were collected through routine key indicators and targets developed by the HAMNASA, which include the number of TB screenings conducted, specimens collected, and the percentage of presumptive TB cases identified and referred. The data were gathered during a month from August- September 2023 in Dili, Timor-Leste. Results: Interviews and focus group discussions revealed several key findings regarding TB management in Timor-Leste. HAMNASA is recognized as pivotal in the effort to combat TB, fostering stakeholder involvement in bolstering the treatment system. The mobile van program, praised by TB district assistants, plays a crucial role in detecting and referring TB cases within health centers. Collaborations with private and non-profit clinics extend services such as chest X-rays and sputum examinations, particularly in Dili. However, challenges persist, including transportation limitations for rural outreach, insufficient community engagement spaces in health centers, and resistance from suspected TB patients. Two among four evaluated CHCs do not consistently follow TB treatment guideline from the Ministry of Health Timor-Leste. Additionally, TB district assistants grapple with economic constraints, long commutes, and patient non-compliance, affecting TB drug adherence. Conclusion: The HAMNASA mobile van has been well received by the community health centers (CHCs) in Dili. However, its impact on TB screening couldn't be measured because the CHCs already had adequate equipment TB care. The Ministry of Health is advised to reassess the national TB treatment protocol, considering if daily visits to CHCs are necessary, increasing patient incentives to improve treatment adherence, and regularly monitoring and evaluating TB patient data management within the CHCs.