SHORTREPORT
'",iALAW| MEDJOURNAL;1 5(2):61-60 JU\E.2003
identifiedin the management Shortfalls for of tuberculosis Mozambicanpatientsobtaininghealth care servicesin Malawi Adamson S Muulal2 MB BS,Yohane Nyasulu'3PhD,Henry Feluzi' Dipl Lab Tech,Collins Magalasi' BA . The Malawi-Mozambique-Zambia (MMZ) International DiseasesNetwork (lDS) ' Department of Community Health, University of Malawi College of Medicine ' Kamuzu College of Nursing, Lilongwe AddressCorrespondenceto: Dr Adamson S. Muula, Department of Community Health, University of Malawi College of Medicine, Private Bag 360, Blantyre 3, Malawi. Fax:(265) 6747OO;Email:[email protected]
Sum m ar y We report findings of a pilot qualitative study in which we aimed to determine management gaps among TB patients from Mozambique obtaining health care services in Malawi. The study was conducted between April and May 2002 involved twelve health workers and 4 Mozambican patients. Semi-structured questionnaires were used and responses were followed up with in-depth interviews. Several areas of management gaps were identified. These included; language
barrier if patients are formally referred with documents in Portuguesel lack of follow-up system in case of patients defaulting; no structured contact-tracing possibilitiesand no initiation of Isoniazid prophylaxis in the caseof children living in households with a sputum smear positive adult case. We conclude that logistical management gaps exist in the management of TB patients from Mozambique obtaining care in Malawian health care facilities.
lntroduction
healtheducationinformation,proceduresfor contacttracing and whetherthere was isoniziadprophylaxisprovided to children of smear-positive Mozambican TB cases who obtain care in Malawi. Data were recordedand categorizedbasedon themes.
The tuberculosis (TB) problem has increasedover the past decadein sub-Saharan Africa mostly due to the HIV/AIDS pandemic '3. For instance,20,630new TB caseswere notified to the Malawi National TuberculosisControl Program(NTP) in 1996, a fourfold increasesince 19864. Malawi's TB treatmentis now decentralizedto health canters and community level using the directly observed therapy (DOTS) 5r'.This means that most administrative roles are carried out at the local level. Each treatment healthfacility has a TB Officer or TB Assistant(who may be a Health SurveillanceAssistant)who reports to the District TB Officer (DTO). The DTO reports to the Zone Officer supervised by the NTP. The NTP acts as a policy formulating body, and conducts periodic supervisory visits and operational research. In 200 1, a network of researchersand civil society organizations formed the Malawi -M ozambique-Zambia International Di seases Surveillance(MMZ-IDS). The network was establishedin order to presenta coordinatedfront towardscross-borderdiseasesprevention and control and is headquarteredin Lusaka, Zambia. As part of ongoingresearchactivities,we conductedthis pilot study to document management gaps pertaining to the care of Mozambicanpatientsobtaining care in Malawian health facilities.
Methods A qualitative study was conducted between April-May 2002 in Mulanje, Mwanza and at Blantyre Adventist Hospital (BAH). Twelve health care workers involved in the managementof TB patientswere interviewedand 4 Mozambicanpatientsobtaining carein Malawi were also interviewed.Responseswere followed up to obtain in-depth information. We aimed to obtain the following information; the languageof communicationused by Mozambicans in Malawi, the mode of referral, areasfrom which Mozambicans who come to Malawi for care come from and reasons why people come to Malawi for care.With particular referenceto TB, the following informationwas sought;sourcesof TB Malawi Medical Joumal
Results Mozambican TB patientsobtain care in Malawi as outpatients and inpatientsin Mulanje, Mwanza District Health Zonesand at Blantyre Adventist Hospital, (BAH). Patients speak N'-anja, Sena, Nyungwe and Portuguese,with the three local languages being understoodby most healthworkerson the Malawian side. Mozambicans attend Malawian health facilities either as their primary care level or as referrals, being both self-referrals and health worker referred. With regard to those individuals formally referral, their documentswere in Portuguese,a languagethat all the health workersinterviewedcould not read nor write. Patients reported preference towards Malawian health facilities becausethey believed that the nearesthealth care facilities in Mozambique are poorly resourced.Attendance at health centers in Mozambiqueis at a consultationis at a fee equivalentto US$ 0.30 and drug costs.Obstetric,child, chronic illnessesand individuals who havecertificationfrom governmentthat they are too poor to pay are exempted.Patientsat BAH pay similar charges as would be requiredof a Malawian. Mozambican patients are registered separately in Mwanza District but not in Mulanje and at BAH. This was due to the fact that in Mwanza, the TB program had been registering high default rates when both Malawian and Mozambican patients were in the sameregister.Health workersin Mwanza perceived Mozambican patients as likely to default than Malawians. Howeverin Mulanje and at the BAH, healthworkersdid not perceive Mozambicanpatientsas differentto Malawian with regard to adherence to treatmenlregimens. In the eventthat a patient does not presentto the health facility for further treatment,health workers reported non-uniform treatment betweenMalawian and Mozambican patients.Generally, there was no systematicfollow-up of patients in their
62 ShortfallsoflB managementfor Mozambicans communities ibr Mozambicans.Exceptionswere howeverwhen the patient was r well-known governmentofficial working for the uniformed seryices(immigration, customsand police). Such patientscould be followed up without diflrculties wilh the immi gration authorities.For other patients,there is no follow-up system in place. Health worters also reportedthat in some cases,they only leam that a particular patient was fiom Mozambique after s/he defaults.The patient may have rcgisteredas a Malawian, giving his or her addressas a village in Malawi. Upon default and follow-up inslituted,that is when it is realizedthat the addresswas 1alse.Health workers repoftedthat it was possiblesomepatients fron Mozambique could give a Malawian village as their home for thinking that by doing so would entitle them to better care. With regard to contact tracing of regular close contactsof sputum smearpositive patients,health workers reported no contact tracing in case of Mozambican patients. Malawian patients should beneflt lron contact, notably children under the age of five years who were householdcontactsof adult smearpositive cases.The main reasongiven for the differencesin care was that Malawian health workers had no jurisdiction over TB treatment and surveillance activitiesin Mozambique.
Discussion This study indicatesthat Mozambicansobtaining care in Malawi are manageddifferently tlom Malawians by virtue of the fact that they stay acrossthe border.Inadequaciesin TB management could resultin an increaseof multi-drugresistantTB 7-10 and adverse patient outcomes, such as prolonged mofbidity and increaseddeaths.There is thereforea need to 'break down'the barriers so that proper care of TB patientsis facilitated between Malawi and Mozarnbique.We suggestthat in order to provide better TB care facilities, there is need for confidential language interpretationservicesother than just using any availableinterpreter; provision of border (immigration) passesfor Malawian health worken following up patients or rathel cooperation affangementswith fellow TB health workers in Mozambique to whom patients can be refen'ed. Malawian and Mozambican healthworkersin borderdistrictscould hold joint professional education sessionsin older to be appraisedon hannonized TB trgatmenIreg]mens. The Southern Africa Development Community (SADC) and Common Market tbr Eastem and SouthernAfrica (COMESA) arepossibletbra at which theseissuescouldbe discussed. Policy makers at all levels need to know that territorial boundariesare posing an obstacle in the proper care of Mozambican TB patientsobtainingcarein Malawianhealthcarefacilities. Acklovl(dsc totts This *rtlt tu.s lio etl b," The Rockefeller Foundatian Intendiona! Dis4ses St^cillanc( Pt?iect, thnush the Centet .lbt Health and Social Scie rcs Resenrch (CTIESSORE).ZLtntbia. We ur( grdteful to Dt Thabdle Ne lrbe, Re3iotnl CootLlitlttat Ior thc I4dlowi-Mo.anhittue antl Zumbia Intematio dl Dilelteli Su^eillatl(e Network. The cooperutk t of putients and healtll wrkers Dl 1e ous, oI the stut/\. is deepl) dpfeckued. The stuth rrds cao&thatut b thc C.ttt(r lbr Hed t tultupulution Stl,.lies,lllalt\ri References I. LlarjcsAD. Tubcrculosis aDdhunranihnunodciiciencyvnnsiniecrionirrdc\.clopinB couDlrics. Lrncet 199(li135:387-390 2. PeniensJH. MukadiY,NunnP Tuberculosis andHIV intccrion:inrplicarions lo.
I 1.
5.
6.
7.
8. 9. l0
A l i i c r . A I D S 1 9 9 1 i . 1 3( S u p p l ) :S l 2 7 - S l 3 l Rcidef HL. Epidemblogic basis oftuberculosis cont.ol. Paris: lntemadonal Union Against Tuberculosis rnd Lung Dis€rse. 1999 Mand€rsAJE. BanerjeeA. \'anden Borne HW. HaricsAD. Kok CJ. SalaniponiFML Crn gurfdians superviseTB treatmenras nella s health {orkcrsl A nudy on rdherence during the intensivephrse. Int J Tuberc Lung Di\ 2001: 5(9): 838'842 Haries AD. Gausi FK. KwrDjda JH, NyircndaTE, Sahniponi FML. ls orai intefmittent irilial phase anli tuber.ul.sis lreatmerl rs$ciated sith higher modalit! in high Hlv-prcvalctrl :rrcasin sub SahatunAtiical Irrt J Tuber! LuDg Dis 2001i 5(5):.181185 Haries AD, Hurg.eave\ NJ. Sllanjponi FM. Dcsign of rcgnneDsibr trealnrg tubcrcukxis in patientswith H] nitction. with pnfticular refe.ence1o sub-Sahirri ' A t i i c a . I n r J T u b c r cL u n g D i s 2 0 0 1 r5 ( 1 2 ) : 1 1 0 9l l 1 5 Enxrson DA. Reider HL, Amadofir T. cr al. Manxgemenr of Tubercuhsis: A Guide for Low hrcome CouDtres. 5lh ed. Paris: Internrtional Union Against Tubcrculosis ard Lung Diseases.2000 Espi.rl MA, Lazzlo A- SiDoDsenL, et al. clobal trends iI rcsistancero a n t j t u b c r c u l o sdi sN g s . N E n g l J M e d 2 0 0 1 ,l : 1 4 r 1 2 9 . 1 - 1 . 1 0 3 MacDonald JB. \'lycobactefiunr tubcrculosisfcsislanceto rjirnrpicil rnd ethrnbutol: aclinical n'n'ey. Thorar 1977i 32:l-4 Mwaungulu FD, CrampinAC, Krnyongolokr H. et al. ADtitubercnlosisdrlg resislanccir KrroDga Drtfict: paltem md lrcrd, I 9 86 200 | . Malawi Med I 2002. l3:l 6
Replyfrom NationalTBControl Programme FelixSalaniponi, AnthonyHarries, NationalTB ControlProgramme,CommunityHealthScienceUnit, PrivateBag65, Lilongwe We welcome the paper by Muula et al on shortfalls in the man agementof TB fbr Mozambican patientswho obtain health care in Malawi. The main problem with the paper is the small number of patients(4) who were interviewed,which makesgeneialisation of the results somewhat difficult. However, interesting nspectsarise fiom this study. The Malawi National TB Progranme (NTP) has been interested for some time in the number of non-Malawian nationals fiom neighbouring countdes who are registeled and startedon anti TB treatment.The NTP is currently collecting data on the magnitude ofthe problem. In many border dist cts, a separateregister is kept of thesepatients.However, the casenumbersand the treatment outcomes are not included and do not appearin any Malawian nationaldata sels.Furthennore,Malawi doesnot send this data to the appropdateTB programmesof the neighbouring countries.These patients are therefore "missing cases" when it comes to global TB casefinding, and this may contribute to the low case detection mtes repofied globally by the World Health Organization. What arc the solutions?Muula et al suggestcross borderTB-follow up activities with plovision of immigration passes fbr Malawi health care workers.This suggestionis probably unrealistic. NTP staff are stretchedat the best of times to follow up Malawian nationals on anti-TB treatment without having to crossover lo neighbouringcountriesto follow up non-Malawian nationals. The legislation required for such immigration passagesnight also take years to sort out. Therc is a body cal1ed the "Southem African TB Control Initiative (SATCI)", which meetsonce a year to explore regional tuberculosisissues.Crossborder notifications and follow-up of patientshas recently been an impoftant item for the agendain the SATCI meetings.[n the next meeting to take place in Maputo, Mozambique, in February 2003, the issue of cross-bordernotification; and follow up of patientswill be one of the leading topics of the agenda.
!.
Malawi Medical Joumal
'",iALAW| MEDJOURNAL;1 5(2):61-60 JU\E.2003
identifiedin the management Shortfalls for of tuberculosis Mozambicanpatientsobtaininghealth care servicesin Malawi Adamson S Muulal2 MB BS,Yohane Nyasulu'3PhD,Henry Feluzi' Dipl Lab Tech,Collins Magalasi' BA . The Malawi-Mozambique-Zambia (MMZ) International DiseasesNetwork (lDS) ' Department of Community Health, University of Malawi College of Medicine ' Kamuzu College of Nursing, Lilongwe AddressCorrespondenceto: Dr Adamson S. Muula, Department of Community Health, University of Malawi College of Medicine, Private Bag 360, Blantyre 3, Malawi. Fax:(265) 6747OO;Email:[email protected]
Sum m ar y We report findings of a pilot qualitative study in which we aimed to determine management gaps among TB patients from Mozambique obtaining health care services in Malawi. The study was conducted between April and May 2002 involved twelve health workers and 4 Mozambican patients. Semi-structured questionnaires were used and responses were followed up with in-depth interviews. Several areas of management gaps were identified. These included; language
barrier if patients are formally referred with documents in Portuguesel lack of follow-up system in case of patients defaulting; no structured contact-tracing possibilitiesand no initiation of Isoniazid prophylaxis in the caseof children living in households with a sputum smear positive adult case. We conclude that logistical management gaps exist in the management of TB patients from Mozambique obtaining care in Malawian health care facilities.
lntroduction
healtheducationinformation,proceduresfor contacttracing and whetherthere was isoniziadprophylaxisprovided to children of smear-positive Mozambican TB cases who obtain care in Malawi. Data were recordedand categorizedbasedon themes.
The tuberculosis (TB) problem has increasedover the past decadein sub-Saharan Africa mostly due to the HIV/AIDS pandemic '3. For instance,20,630new TB caseswere notified to the Malawi National TuberculosisControl Program(NTP) in 1996, a fourfold increasesince 19864. Malawi's TB treatmentis now decentralizedto health canters and community level using the directly observed therapy (DOTS) 5r'.This means that most administrative roles are carried out at the local level. Each treatment healthfacility has a TB Officer or TB Assistant(who may be a Health SurveillanceAssistant)who reports to the District TB Officer (DTO). The DTO reports to the Zone Officer supervised by the NTP. The NTP acts as a policy formulating body, and conducts periodic supervisory visits and operational research. In 200 1, a network of researchersand civil society organizations formed the Malawi -M ozambique-Zambia International Di seases Surveillance(MMZ-IDS). The network was establishedin order to presenta coordinatedfront towardscross-borderdiseasesprevention and control and is headquarteredin Lusaka, Zambia. As part of ongoingresearchactivities,we conductedthis pilot study to document management gaps pertaining to the care of Mozambicanpatientsobtaining care in Malawian health facilities.
Methods A qualitative study was conducted between April-May 2002 in Mulanje, Mwanza and at Blantyre Adventist Hospital (BAH). Twelve health care workers involved in the managementof TB patientswere interviewedand 4 Mozambicanpatientsobtaining carein Malawi were also interviewed.Responseswere followed up to obtain in-depth information. We aimed to obtain the following information; the languageof communicationused by Mozambicans in Malawi, the mode of referral, areasfrom which Mozambicans who come to Malawi for care come from and reasons why people come to Malawi for care.With particular referenceto TB, the following informationwas sought;sourcesof TB Malawi Medical Joumal
Results Mozambican TB patientsobtain care in Malawi as outpatients and inpatientsin Mulanje, Mwanza District Health Zonesand at Blantyre Adventist Hospital, (BAH). Patients speak N'-anja, Sena, Nyungwe and Portuguese,with the three local languages being understoodby most healthworkerson the Malawian side. Mozambicans attend Malawian health facilities either as their primary care level or as referrals, being both self-referrals and health worker referred. With regard to those individuals formally referral, their documentswere in Portuguese,a languagethat all the health workersinterviewedcould not read nor write. Patients reported preference towards Malawian health facilities becausethey believed that the nearesthealth care facilities in Mozambique are poorly resourced.Attendance at health centers in Mozambiqueis at a consultationis at a fee equivalentto US$ 0.30 and drug costs.Obstetric,child, chronic illnessesand individuals who havecertificationfrom governmentthat they are too poor to pay are exempted.Patientsat BAH pay similar charges as would be requiredof a Malawian. Mozambican patients are registered separately in Mwanza District but not in Mulanje and at BAH. This was due to the fact that in Mwanza, the TB program had been registering high default rates when both Malawian and Mozambican patients were in the sameregister.Health workersin Mwanza perceived Mozambican patients as likely to default than Malawians. Howeverin Mulanje and at the BAH, healthworkersdid not perceive Mozambicanpatientsas differentto Malawian with regard to adherence to treatmenlregimens. In the eventthat a patient does not presentto the health facility for further treatment,health workers reported non-uniform treatment betweenMalawian and Mozambican patients.Generally, there was no systematicfollow-up of patients in their
62 ShortfallsoflB managementfor Mozambicans communities ibr Mozambicans.Exceptionswere howeverwhen the patient was r well-known governmentofficial working for the uniformed seryices(immigration, customsand police). Such patientscould be followed up without diflrculties wilh the immi gration authorities.For other patients,there is no follow-up system in place. Health worters also reportedthat in some cases,they only leam that a particular patient was fiom Mozambique after s/he defaults.The patient may have rcgisteredas a Malawian, giving his or her addressas a village in Malawi. Upon default and follow-up inslituted,that is when it is realizedthat the addresswas 1alse.Health workers repoftedthat it was possiblesomepatients fron Mozambique could give a Malawian village as their home for thinking that by doing so would entitle them to better care. With regard to contact tracing of regular close contactsof sputum smearpositive patients,health workers reported no contact tracing in case of Mozambican patients. Malawian patients should beneflt lron contact, notably children under the age of five years who were householdcontactsof adult smearpositive cases.The main reasongiven for the differencesin care was that Malawian health workers had no jurisdiction over TB treatment and surveillance activitiesin Mozambique.
Discussion This study indicatesthat Mozambicansobtaining care in Malawi are manageddifferently tlom Malawians by virtue of the fact that they stay acrossthe border.Inadequaciesin TB management could resultin an increaseof multi-drugresistantTB 7-10 and adverse patient outcomes, such as prolonged mofbidity and increaseddeaths.There is thereforea need to 'break down'the barriers so that proper care of TB patientsis facilitated between Malawi and Mozarnbique.We suggestthat in order to provide better TB care facilities, there is need for confidential language interpretationservicesother than just using any availableinterpreter; provision of border (immigration) passesfor Malawian health worken following up patients or rathel cooperation affangementswith fellow TB health workers in Mozambique to whom patients can be refen'ed. Malawian and Mozambican healthworkersin borderdistrictscould hold joint professional education sessionsin older to be appraisedon hannonized TB trgatmenIreg]mens. The Southern Africa Development Community (SADC) and Common Market tbr Eastem and SouthernAfrica (COMESA) arepossibletbra at which theseissuescouldbe discussed. Policy makers at all levels need to know that territorial boundariesare posing an obstacle in the proper care of Mozambican TB patientsobtainingcarein Malawianhealthcarefacilities. Acklovl(dsc totts This *rtlt tu.s lio etl b," The Rockefeller Foundatian Intendiona! Dis4ses St^cillanc( Pt?iect, thnush the Centet .lbt Health and Social Scie rcs Resenrch (CTIESSORE).ZLtntbia. We ur( grdteful to Dt Thabdle Ne lrbe, Re3iotnl CootLlitlttat Ior thc I4dlowi-Mo.anhittue antl Zumbia Intematio dl Dilelteli Su^eillatl(e Network. The cooperutk t of putients and healtll wrkers Dl 1e ous, oI the stut/\. is deepl) dpfeckued. The stuth rrds cao&thatut b thc C.ttt(r lbr Hed t tultupulution Stl,.lies,lllalt\ri References I. LlarjcsAD. Tubcrculosis aDdhunranihnunodciiciencyvnnsiniecrionirrdc\.clopinB couDlrics. Lrncet 199(li135:387-390 2. PeniensJH. MukadiY,NunnP Tuberculosis andHIV intccrion:inrplicarions lo.
I 1.
5.
6.
7.
8. 9. l0
A l i i c r . A I D S 1 9 9 1 i . 1 3( S u p p l ) :S l 2 7 - S l 3 l Rcidef HL. Epidemblogic basis oftuberculosis cont.ol. Paris: lntemadonal Union Against Tuberculosis rnd Lung Dis€rse. 1999 Mand€rsAJE. BanerjeeA. \'anden Borne HW. HaricsAD. Kok CJ. SalaniponiFML Crn gurfdians superviseTB treatmenras nella s health {orkcrsl A nudy on rdherence during the intensivephrse. Int J Tuberc Lung Di\ 2001: 5(9): 838'842 Haries AD. Gausi FK. KwrDjda JH, NyircndaTE, Sahniponi FML. ls orai intefmittent irilial phase anli tuber.ul.sis lreatmerl rs$ciated sith higher modalit! in high Hlv-prcvalctrl :rrcasin sub SahatunAtiical Irrt J Tuber! LuDg Dis 2001i 5(5):.181185 Haries AD, Hurg.eave\ NJ. Sllanjponi FM. Dcsign of rcgnneDsibr trealnrg tubcrcukxis in patientswith H] nitction. with pnfticular refe.ence1o sub-Sahirri ' A t i i c a . I n r J T u b c r cL u n g D i s 2 0 0 1 r5 ( 1 2 ) : 1 1 0 9l l 1 5 Enxrson DA. Reider HL, Amadofir T. cr al. Manxgemenr of Tubercuhsis: A Guide for Low hrcome CouDtres. 5lh ed. Paris: Internrtional Union Against Tubcrculosis ard Lung Diseases.2000 Espi.rl MA, Lazzlo A- SiDoDsenL, et al. clobal trends iI rcsistancero a n t j t u b c r c u l o sdi sN g s . N E n g l J M e d 2 0 0 1 ,l : 1 4 r 1 2 9 . 1 - 1 . 1 0 3 MacDonald JB. \'lycobactefiunr tubcrculosisfcsislanceto rjirnrpicil rnd ethrnbutol: aclinical n'n'ey. Thorar 1977i 32:l-4 Mwaungulu FD, CrampinAC, Krnyongolokr H. et al. ADtitubercnlosisdrlg resislanccir KrroDga Drtfict: paltem md lrcrd, I 9 86 200 | . Malawi Med I 2002. l3:l 6
Replyfrom NationalTBControl Programme FelixSalaniponi, AnthonyHarries, NationalTB ControlProgramme,CommunityHealthScienceUnit, PrivateBag65, Lilongwe We welcome the paper by Muula et al on shortfalls in the man agementof TB fbr Mozambican patientswho obtain health care in Malawi. The main problem with the paper is the small number of patients(4) who were interviewed,which makesgeneialisation of the results somewhat difficult. However, interesting nspectsarise fiom this study. The Malawi National TB Progranme (NTP) has been interested for some time in the number of non-Malawian nationals fiom neighbouring countdes who are registeled and startedon anti TB treatment.The NTP is currently collecting data on the magnitude ofthe problem. In many border dist cts, a separateregister is kept of thesepatients.However, the casenumbersand the treatment outcomes are not included and do not appearin any Malawian nationaldata sels.Furthennore,Malawi doesnot send this data to the appropdateTB programmesof the neighbouring countries.These patients are therefore "missing cases" when it comes to global TB casefinding, and this may contribute to the low case detection mtes repofied globally by the World Health Organization. What arc the solutions?Muula et al suggestcross borderTB-follow up activities with plovision of immigration passes fbr Malawi health care workers.This suggestionis probably unrealistic. NTP staff are stretchedat the best of times to follow up Malawian nationals on anti-TB treatment without having to crossover lo neighbouringcountriesto follow up non-Malawian nationals. The legislation required for such immigration passagesnight also take years to sort out. Therc is a body cal1ed the "Southem African TB Control Initiative (SATCI)", which meetsonce a year to explore regional tuberculosisissues.Crossborder notifications and follow-up of patientshas recently been an impoftant item for the agendain the SATCI meetings.[n the next meeting to take place in Maputo, Mozambique, in February 2003, the issue of cross-bordernotification; and follow up of patientswill be one of the leading topics of the agenda.
!.
Malawi Medical Joumal
