Malawi

Malawi is located in southeast Africa and in 2005 had a population of 11.4 million. Malawi is one of the sub-Saharan African countries with the highest TB burdens. TB is the most important single cause of adult illness and death from a communicable disease in Malawi. DOTS coverage remained at 100% in all the districts in 2004/2005. Both the 2004/2005 TB detection and cure rates targets set at 70% and 75% respectively were not achieved. The district treatment success rates ranged from 58-98%, with an average of 78%, making it likely that this measure could be achieved. The defaulter rates have decreased to 3% in the 2004 cohort of new ss+ positive patients.

Case detection under DOTS is estimated by WHO at 52% in the 2006 report (2004 data for all forms of tuberculosis). The burden of TB and HIV/AIDS pose unprecedented challenges on the public health system in Malawi. The country had 27,610 TB patients registered in 2005, almost a six fold increase since 1983 (NTP, 2005). The consequences of this sharp rise in TB go beyond simple health concerns, and drains resources from other essential health and welfare services if quality services are to be maintained.

Malawi has an HIV/AIDS prevalence of 14.4%, and more than 900,000 adults and children are living with HIV/AIDS (NAC Technical Report, 2003).

The Malawi National TB Program is well known for its achievements in TB control. Malawi was one of the first countries where the DOTS strategy was successfully piloted in the early eighties. The NTP is regarded as one of the well functioning DOTS programs in the African region.

TB CAP Highlights Malawi

Using audits to reduce TB deaths
Just as is the case with death from all other causes, deaths resulting from TB have continued to be worrisome to the NTP and other stakeholders in Malawi. The situation in TB CAP Districts of Mangochi and Zomba has been similar. In the past any death of a registered TB Patient has been reported as resulting from TB despite of other causes which could have been reported as the major causes like pneumonia, anaemia, HIV/AIDS etc, in line with the WHO definition. This resulted in high numbers of TB patients registered to have died during treatment while their death could have resulted from another disease than TB.

NTP was worried about the quality of clinical care of admitted TB patients. Therefore NTP instituted death audits at hospital level, necessitating that each death of a TB Patient be scrutinized in detail. This exercise could also improve the management of TB patients at both treatment centers and facilities during the continuation phase. TB CAP has been supporting the death audits since the last quarter (October- December) of 2007 for TB Patients. Specifically the death audits aim at;

• Increasing the frequency of ward rounds in the TB ward
• Establishing the real cause of death among TB patients in the hospital
• Improve on patient history taking and documentation for informed decision making at both the facility and community levels.
• Identify gaps in the management of TB patients

TB CAP assisted in auditing 80 TB deaths in Zomba and 32 in Mangochi since the implementation of the initiative. Since the initiative started, gaps revealed during the audits have prompted deployment of more clinical and nursing staff into TB wards. Zomba Central Hospital has increased the number of nurses allocated to the TB ward from 2 to 4 while the number at Mangochi Hospital has been increased from 2 to 3.

After the initiative, the districts have also allocated full time clinical staff for the TB wards unlike before when no specific clinical officers were responsible for the TB ward. Both Mangochi and Zomba have one focal TB clinical officer each in addition to the support that they get from their colleagues in the other medical wards. Subsequently, the two districts have seen an increase in number of ward rounds in the TB wards per month. Zomba Central Hospital has increased the number of ward rounds to 13 per month from an average of 4 that used to take place. In Mangochi the number has increased to eight from four.

Recent supervision reports have also indicated an improvement by the nursing staff in taking vital signs among TB patients admitted in both hospitals. The death audits have acted as catalyst among health workers deployed in the TB Wards to ensure that vital signs are checked and taken frequently, and action is taken as needed. All these are pointing towards an improved provision of care among TB patients. Some reduction in the death rate among TB patients is being registered i.e. 3% in the previous quarter from around 16% before the interventions as reported at Zomba Central Hospital and 16.9% in Mangochi in the second quarter of 2007 when the project was just starting.

Existing guidelines at national level (conducting death audits) require clear interpretation, support, creativity in execution and evidence based decision making by managers at hospital implementation level in order to improve quality of care being provided to TB patients thereby preventing deaths that occur due to obvious or human errors.

• Information captured on the death audit form is not exhaustive enough. There is need to review the death audit tool in collaboration with NTP and TB coordinators from the districts. Documentation of the whole process is required from structures, tools, data management, how the sessions are conducted in order to inform program management and decision makers.
• Rotation of staff trained in TB activities between facilities and other wards i.e. from TB Ward to Maternity Wing and even between districts.
• Limited knowledge of health workers on the management of opportunistic infections. There is need for expanding the trained number through on-the- job and classroom training.
• Limited accessibility of ARV services by TB patients due to quota system. Need for discussion between NTP and HIV Unit.
• Competing priorities among the members involved in the audits. This leads to rescheduling of the activities in some instances.

TB CAP Project Period (2005-2010)

Expected output(s)

• Continuum of integrated care for TB/HIV
• Improve laboratory capability
• Improved Public / Private Mix
• Human Resource Development