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Talia Kostal
March 5, 2014
TA: Roman XU

Global Fund Assignment #7
Disease & Country: TB in Haiti
1) Introduction & Overview
According to the Library of Congress Research Division, Haiti ranks last in
healthcare spending in the Western Hemisphere ("Country profile: Haiti," 2006). The
already fragile government in Haiti took a major hit in January 2012, when a devastating
7.0 earthquake hit the region. Since then, due to economic and political instability and
ineffectiveness, there remains a lack of commitment to health spending and
improvements in infrastructure. This leaves more than 50% of the population without
reliable access to clean drinking water, 57% without much needed immunizations, and
many with minimal to no access to preventative healthcare ("Haiti overview," 2014). As a
result, life expectancy in Haiti at birth remains at 44 years of age ("Haiti overview,"
2014).
While Haiti falls well below many countries in the Latin American and Caribbean
region when it comes to health indicators, perhaps the most startling is the prevalence of
Tuberculosis (TB) in the country. While in neighboring regions the prevalence of TB
averages 36 active cases per 100,000 people, in Haiti the prevalence is nearly ten-fold,
with an average of 300 active cases per 100,000 people ("Cases: Mortality and," 2014).
According to the Centers for Disease Control, there is a significant lack of governmental
infrastructure dedicated to surveillance and treatment of TB in Haiti. Due to inadequate
access to rapid diagnostic testing, especially in secondary cities, the CDC reports that the
case-detection rate of TB in 2010 was only 47%, and of this group only 71% received
adequate treatment ("Country profile: Haiti," 2006). A gap this significant demands
attention, and adequate funds to provide a quality intervention.
To address this issue we propose a strategy to increase the availability of
diagnostic testing in Cap Haitian, a city in northern Haiti in a region with high population
density, high TB prevalence, and minimal resources for TB surveillance and treatment
(Ho & Morose, 2013). Although Cap Haitian is one of the major cities outside of the
Port-au-Prince its health posts lack the fundamental diagnostic testing needed to
adequately identify and treat the high prevalence of TB in the area. Among the three
treatment centers in the region, only one has the ability to provide diagnosis via x-ray,
another has the ability to identify TB through microscopy in the laboratory, and one has
neither x-ray or microscopy resources (Ho & Morose, 2013). We propose to the use the
grant funding to equip the local treatment centers in the area with either the needed x-ray
and/or laboratory technology to ensure patients can benefit from rapid diagnostic testing,
as well as create a fleet of mobile dialogistic TB clinics. Additionally, we propose to use
funding to train and hire local staff dedicated solely to x-ray and microscopy detection of
TB at the three established sites in Cap Haitian. In the staff training modules we propose
to implement coaching on how to educate the TB patients identified through these
methods on the importance of adhering to treatment, as well as available resources in the
area to support them during their prescribed DOTS therapy.
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The graphic and map below clarifies the logic of the proposed intervention:















https://mapsengine.google.com/map/u/0/edit?mid=zd0FhZPFiYSc.kINQ3E5XLSCs
2) Goals & Impact

The proposed intervention has two main goals: (1) to increase the case detection
rate of TB in the Cap Haitian region and (2) to increase the percentage of those who are
identified as having active TB who go on to complete adequate treatment.

The goal to increase the
case detection rate of TB will
have a positive impact on both
the target population, as well as
the local burden of disease.
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Increased case detection rates will have a favorable impact for each new individual
identified, as well as the surrounding community. Increasing the case detection rate will
ultimately increase the number of people in the population eligible to receive life-saving
DOTS treatments. Although an increase in case detection rates will initially be marked by
a spike in incidence rates, in the long-term, more cases identified means more cases
treated, which in turn will ultimately decrease the burden of disease in the area.

The goal to increase the percentage of identified TB cases that complete an
adequate treatment regimen in the Cap Haitian region will have a significant impact on
reducing the burden of disease as well. The typical course of treatment for a TB infection
is six to nine months of strict antibiotic therapy ("Tb treatment," 2014). In a resource
poor setting such as Cap Haitian, it can be difficult for patients to adhere to their
prescribed regimens for a variety of reasons. However when TB is treated with an
inadequate course of antibiotics, it can lead to drug resistant TB, an outcome that is
incredibly dangerous for both an individual as well the population at large ("Tb
treatment," 2014). Since TB is an infectious disease, when a person does not complete
adequate treatment drug resistant TB it can be spread to others who are uninfected in the
larger population. In a resource poor setting such as Cap Haitian second-line drugs
needed to treat drug resistant TB are often expensive and difficult to access. As a result
inadequate treatment regimens can drastically increase the burden of disease in the
population. The goal of increasing the percentage of people who complete adequate TB
treatment would have the potential to impact the burden of disease in a positive
way.
3) Objectives & Outcomes

There are four main objectives that are aimed to help realize the stated goals as
outlined in Section two. The four main objectives are: (1) increase the number of health
centers in Cap Haitian equipped with both x-ray and microscopy technology; (2) increase
the number of local health workers
trained in microscopy or radiology; (3)
increase number of staff trained in
patient education strategies; (4)
increase the percentage of people who
have access to adequate diagnostic
healthcare.
The objective of increasing the
number of health centers in Cap
Haitian equipped with both x-ray and
microscopy technology ties directly to
the goal of increasing the case detection rate of TB in the Cap Haitian region. By
providing the needed radiology and laboratory technologies, the health posts that are
already present in the region will have the ability to provide rapid diagnostic testing
services to those most in need. This in turn will increase the number of people who are
identified and fast tracked into treatment. As a result, the burden of disease will be
lowered and an increased in TB health outcomes in the greater population should be
observed.
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The objective of increasing the number of local health workers trained in
microscopy or radiology also ties directly back to increasing the case detection rate of TB
in the region. Increasing the local staff trained in such techniques will have a two-fold
impact. One, it will provide jobs and income to the local population which will serve to
stimulate the local economy. Additionally Haiti has a known shortage of healthcare
personnel. Currently Haiti only has 11 nursing/midwifery personnel and 25 doctors per
100,000 people, a rate that falls well below the regional average ("Health system report:"
2013). Training technicians qualified to diagnose TB will increase the number of health
care providers available to identify those in need of treatment, which in turn should
increase the case detection rate and decrease the burden of disease.
The objective of increasing number of community health workers trained in
patient education strategies ties to the goal of increasing the percentage of people who
complete adequate treatment for diagnosed TB. Health workers that are part of the
radiology and microscopy training programs will also receive coaching in strategies to
provide consistent education to patients who are newly diagnosed with TB. Providing
education to patients on the importance of, and safety issues surrounding, proper
completion of treatment, as well as the resources available to help them do so, should
increase the number of people who complete adequate treatment regimens. This should in
turn decrease the number of people who suffer from, and infect others with, drug resistant
TB, which will increase the positive health outcomes for the greater population in the
Cap Haitian region.
The final outcome indicator is the percentage of people who have access to
medical providers who have the capability to correctly and efficiently diagnose TB. The
number of people who have access to proper diagnostic care is a key indicator in
evaluating how well the program is progressing towards its stated goals.
4) Practical Activities

There are five main activities
related to the objectives stated in section
three, which can be seen in the table
(right).
The two activities which focus
on community health worker education
can be discussed together as the
programs have many overlapping
qualities. The education programs are
designed to recruit local health workers
into dedicated training programs
designed to provide education on proper
identification of TB using x-ray
technology or laboratory microscopy. At
the end of the program the health
workers will be qualified to work either
in the local hospitals, or in mobile TB
clinics. We propose that the Haitian
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Ministry of Health be equipped with training materials and teachers for these programs
donated by the NGO Partners in Health. In the first year of the program we hope to
graduate one cohort of 20 health workers in each specialty and in five years graduate 5
cohorts of 20 health workers in each specialty. These programs will increase the number
of health workers capable of preforming proper diagnostic techniques, which turn will
increase the number of people who will have access to diagnostic TB healthcare,
increasing the case detection rate of TB, and ultimately lowing the overall prevalence of
TB in the region.
Additionally, we propose that all students in the x-ray and microscopy programs,
as well as staff already working in hospital TB clinics, be required to have dedicated
recurrent training in patient education strategies. We propose that the Ministry of Health
implement mandated health worker trainings that covers how and why patients can and
need to adherence to their treatment regimen, as well as resources in the community that
can help them complete their course of antibiotics. We propose that in the first year all
health workers receive at least one patient education training every two years and in five
years all workers will receive training twice every year. These training programs are
designed to help increase the number of people that have already been diagnosed with TB
complete an adequate treatment regimen and to decrease the incidence of drug resistant
TB in the community.
We also propose that gifts-in-kind donations be made to the three established
health centers in Cap Haitian. We propose that Royal Phillips Electrics donate x-ray and
microscopy technologies to three health centers that lack these much-needed devices. We
propose that Royal Phillips electrics donate two Bucky Dignost x-ray machines, and two
suites of microscopes (working document, 2008). We hope that by the end of the first
year two out of the three hospitals will be fully equipped with both technologies, and that
by the end of five years all three hospitals have up to date x-ray and microscopy
technologies. Increasing the number of hospitals capable of proper TB identification will
increase the case detection rate in Cap Haitian.
We also propose the donation of five trucks equipped with mobile x-ray
technology to the Ministry of Health for use in the Cap Haitian region. We propose that
these gifts-in-kind also be made from Royal Phillips Electrics from their Pratix Mobile
Radiology line (working document, 2008). Having a fleet of mobile TB clinics will allow
those living in outlying areas access to life-saving technologies. The health workers
trained in the proposed education programs will be eligible to operate the mobile TB
clinics, which will have the capability to both diagnose, as well as educate patients.
Mobile TB clinics will work to increase the number of people with access to TB
diagnostic care and TB education, and ultimately increase case-detection rates, and
decrease prevalence in the region.
5) Filling the Gaps

According to the Centers for Disease Control, there is a significant lack of
governmental infrastructure dedicated to surveillance and treatment of TB in Haiti. As a
result of lack of governmental health programs dedicated to TB surveillance and
treatment, a majority of those in Haiti receive TB related health services through NGOs.
Haiti Partners In Health is one of the most prominent programs working to improve TB
treatment outcomes, specifically through the use of DOTS implemented by community
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health workers. In a DOTS program patients receive additional support and supervision
during their six to eight month course of antibiotics to ensure successful treatment of the
disease ("Tb treatment," 2014). While DOTS therapy has greatly improved health
outcomes for those receiving treatment, one must be diagnosed with TB first in order to
receive it. Our proposed intervention attempts to bridge the gap between those who have
TB but have not yet being diagnosed, and those receiving DOTS treatments.
The Global Fund is one of the main international donor agencies involved in the
national fight to identify and treat tuberculosis. To date, the Global Fund has committed
$27,335,337 USD in grant money to fighting TB in Haiti ("The global fund," 2013). The
grant money provided by the Global Fund works to strengthen and bridge the gaps in the
health system already present in Haiti. Although the scale up of the DOTS programs have
drastically increased the number of people receiving TB treatment, Haiti still has one of
the highest prevalence of active TB in the region and the cure rate for those who are
diagnosed with TB is only 84%("Tuberculosis: Treatment success," 2014). Our program
aims to help mitigate these existing gaps by increasing the case detection rate, training
health care workers, and educating patients in the Cap Haitian region.
6) Goals & Specific Issues

Involvement of beneficiaries
Our proposal involves the beneficiaries (people currently infected with TB but not yet
diagnosed) on the most basic level. Increasing the total case detection rate of TB in the
Cap Haitian region through an increase in trained community health workers qualified to
provide diagnostic care will increase the positive health outcomes for those infected with
TB. The intervention we propose occurs at a grassroots level, and the impact to our
primary beneficiaries will be immediate. Additionally, the proposal will benefit
secondary beneficiaries (people who are not yet infected with TB) as increasing the
number of cases identified and successfully treated will decrease the incidence of TB in
the long-run.

Community participation
The success of our program is founded primarily on community participation. Through
the use of community health workers already familiar with the culture and terrain of the
Cap Haitian region we hope to build trust and encourage local community members to
participate in our TB screening programs available in both the mobile TB clinics, as well
as the three main health centers within the city.

Gender equality issues
According to USAID, gender based violence is a major issue in Haiti, especially
following the 2010 earthquake. Although our program does not aim specifically to
address issues of gender-based violence in Cap Haitian, it does work to provide
vocational training to women in the area. USAID sites poverty and lack of economic
opportunity as root causes of the gender-based violence routinely seen in Haiti ("Gender
equity and," 2014). Through vocational training in radiology and microscopy women are
given the skills to find employment and rise up out of poverty.

Social equality issues
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According to the World Bank, Haiti is the poorest, and one of the most unequal, countries
in the Northern Hemisphere ("Haiti overview," 2014). Our proposal aims to address
issues of social equality in two distinct ways. First, we approach the provision of our
services through an equity-based approach in that our assistance is free of charge.
Anyone is eligible to receive diagnostic screening and education from our mobile or
stationary units. Additionally, we have chosen to focus our efforts in the Cap Haitian
region due to the inequity of health services available in the northern part of the country.
Although the region exhibits a high population density and TB prevalence, the existing
health centers are not adequately equipped to diagnose and treat the TB in the region (Ho
& Morose, 2013). Our proposal seeks to bring health equity for all facing a TB diagnosis
in the Cap Haitian region.

Human resources development
Currently Haiti only has 25 doctors and 11 nursing/midwifery personnel per 100,000
people, a rate that falls well below the regional average ("Health system report:" 2013).
Through privately funded and implemented programs such as our proposed intervention,
community healthcare workers are able to fill some of the gaps in this system. Our
proposal to train local community health workers in radiology and microscopy techniques
specifically aims address the dire lack of human resources in healthcare in Haiti, and
more specifically in the Cap Haitian region.
7) Opposition & Response

There are several potential points of opposition to a privately funded project such as our
proposed intervention. Below is a list of a few points of possible contention, and how we
aim to address each:
Will the proposal be sustainable?
Yes, by educating local community health workers we are providing the
necessary assets (equipment, education, etc.) for the local community in Cap
Haitian to continue the program after its initial implementation.
How will donations be used?
We have very specific goals and objectives for this proposal. Money will be used
to create educational training programs and pay community health workers.
Gifts-in-kind will be given and used at specific mobile or stationary clinics.
How can we evaluate if the program is working?
At the end of one year, and the end of five years, we will work with the local
government, as well as the Haitian Ministry of Health, to measure the
prevalence, incidence, and mortality rate of TB in both the Cap Haitian region
and Haiti as a whole.

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Work Cited:

1. (2014). Haiti overview. Retrieved from The World Bank Group website:
http://www.worldbank.org/en/country/haiti/overview

2. Centers for Disease Control and Prevention, (2014). Tb treatment. Retrieved from
website: http://www.cdc.gov/tb/topic/treatment/default.htm

3. Federal Research Division , (2006). Country profile: Haiti. Retrieved from
Library of Congress website: http://lcweb2.loc.gov/frd/cs/profiles/Haiti.pdf

4. Global Health Observatory Data Repository, (2014). Cases: Mortality and
prevalence by country (2007 - present). Retrieved from World Health
Organization website: http://apps.who.int/gho/data/node.main.1317?lang=en

5. Global Health Observatory Data Repository, (2014). Tuberculosis: Treatment
success by country. Retrieved from website:
http://apps.who.int/gho/data/node.main.1335?lang=en

6. Ho, J., & Morose, W. (2013). Haitis tb active strategic implementation plan.
Informally published manuscript, Southeastern National Tuberculosis Center ,
Retrieved from http://sntc.medicine.ufl.edu/Files/Haiti/Strategic Implementation
Plan JHo.pdf

7. The global fund: Haiti . (2013). Retrieved from
http://portfolio.theglobalfund.org/en/Country/Index/HTI

8. Working document on chest x-ray equipment for use in tb prevalence surveys In
(2008). KNCV Tuberculosis Foundation . Retrieved from
http://www.who.int/tb/advisory_bodies/impact_measurement_taskforce/meetings/
prevalence_survey/chest_x_ray_eqpt.pdf

9. USAID, (2014). Gender equity and women's empowerment. Retrieved from
website: http://www.usaid.gov/haiti/gender-equity-and-womens-empowerment

10. USAID, Health Finance & Governance (2013). Health system report: Haiti.
Retrieved from website: http://www.hfgproject.org/resources/health-systems-
database/country-profiles/haiti/