TB patient is taking pills practicing video observed treatment . Photo: Kairat Murzakimov / USAID

Yulia Aleshkina works as a Monitoring and Evaluation (M&E) specialist for the UNDP / Global Fund project. In this blog, she tells us how the Covid-19 pandemic changed the UNDP’s team approach to monitoring, which needs of key groups are prioritized and how this influences decisions and management of the project as a whole.

Monitoring and Evaluation (M&E) is an important component for any project or program, as it allows to detect problems at early stages and take timely steps to solve them. But at the forefront of any project component including M&E stand the people for whom we work: our beneficiaries. Our project’s target group includes the most vulnerable layers of our society - people with severe illnesses, who need long or even life-long treatments (HIV and tuberculosis), people with addictions – and some of the most stigmatized groups of the population – sex workers and LGBT. This is why our work is based on these questions: “Does our work really correspond to the needs of our beneficiaries; does our work significantly impact their lives; and does this lead to noticeable results in the society as a whole?”

To anticipate means to manage 

When, by the end of February, it became obvious that Covid-19 was spreading across the world and that its appearance in Kyrgyzstan was just a matter of time, our team started to actively look for new approaches to our work. It was necessary to think about how to maintain effective project management in these new and unknown conditions, and how to continue providing uninterrupted access to prevention, diagnostic and treatment services to our target group. 

When, by the end of February, it became obvious that Covid-19 was spreading across the world and that its appearance in Kyrgyzstan was just a matter of time, our team started to actively look for new approaches to our work. It was necessary to think about how to maintain effective project management in these new and unknown conditions, and how to continue providing uninterrupted access to prevention, diagnostic and treatment services to our target group.

To begin with, we tried to visit as many organizations working within the Global Fund project grant as we could before the instauration of the emergency situation then emergency state. And when the emergency state was declared, we began introducing new methods for routine monitoring: online surveys for the staff and clients of partner organizations, online monitoring, and regular meetings on What’s App or Zoom. We are always connected with our key organizations, 24 hours a day, 7 days a week. All of this allows us to timely identify weaknesses and, when possible, react. 

Medical specialist using online tool for observance of TB patients. Photo: Kairat Murzakimov / USAID

The importance of innovations in treatment

In March 2020 there were already a few publications on the UNDP site about the importance of being on a controlled treatment for patients with TB, and the importance for them to be in contact with health care workers and to receive informative and psychological support. Under normal circumstances, many patients with drug-resistant TB get tired of their treatment and skip some pills, and sometimes even stop taking their treatment for a few days, weeks, or all together. Even a small interruption in TB treatment can lead to poor treatment outcomes, and patients can develop resistance to drugs that used to “work” before. So it was even more important to provide controlled treatment under the emergency state, when additional factors of stress appear for patients: a threat of new diseases, necessary isolation, uncertainty, unemployment and a lack of money. It’s not enough to just give out pills to patients: we have to make sure that patients take them all and every day.

In March, our monitoring of health organizations providing TB diagnostic and treatment in the regions of Osh and Chuy showed that the coverage of alternative treatment methods was still very low, and many doctors and nurses on site didn’t know how to use video observed treatment (VOT). VOT is carried out by the health care worker responsible for TB treatment (usually, the family nurse). Patients receive their medicine for 1-2 weeks in advance. Every day, they video-call their nurse and take their treatment live, under control. If the patient does not have Internet coverage at home, then they are asked to record videos of their treatment intake for several days and send all of these videos to the nurse when they can. This allows patients to lower their number of visits to the clinic, save time and money, and it is a great alternative for patients who are in difficult situations (for example, patients with children, patients who cannot walk…).

In February 2020, only 123 out of 1353 patients with drug-resistant forms of TB were on VOT (9%) and 68 patients (5%) received their treatment through a treatment supporter.

Before the beginning of the emergency state, we held discussions with the National TB Program to transfer all adherent patients to alternative controlled treatment methods and hand out anti-TB pills for longer periods of time. At the same time, we asked our case managers to train health care workers and patients to use VOT. At the end of March, the number of patients on VOT already increased to 362 (26.8%), and at the end of April there were 386 (27.5%) patients on VOT.  The National TB Center timely reacted to the new situation, and on April 8, the Ministry of Health signed the Order n225 “On the provision of TB services under emergency situation and emergency state in the Kyrgyz Republic”, which allows to transfer all patients with TB on VOT and to give pills to TB patients for 14 days at a time. 

What is controlled is done better

But for a good order to work we need time and resources, that, at the moment of the emergency state, the MOH, the NTP and the Family Health Care Centers didn’t’ have. Most of the clinics and the patients weren’t ready to switch to VOT. That’s why our project, which provides the drugs for the treatment of drug-resistant TB, was worried about how this Order would be fulfilled and what we could do to ensure that treatment would continue to be controlled.

Between May 10 and 15, we conducted a monitoring of the quality of VOT. Through our case managers in the region, we controlled VOT by organizing a randomized selection of 39 patients out of 386 on VOT. We asked them to share at least one video of their treatment intake for the last week. We only received 24 videos, and some of these were filmed only after our request. The content of some of these videos clearly showed that for some of the patients and the health care workers responsible for their treatment, this was a first experience using VOT. We concluded that VOT was not used regularly like it should.

This simple exercise allowed us to solve several tasks. First, now patients and health care workers know that VOT is under control, and they will be more careful about implementing it. Second, we noticed technical problems linked to the safe and correct intake of TB pills. On this basis, clinical coordinators and case managers will contact each facility individually and give recommendations. And third, this allowed us to understand which minimal resources were necessary to correctly implement VOT. The main problem we encountered was patients’ and medical workers’ lack of money to pay for Internet on their phone. The UNDP then decided that all patients on ambulatory treatment, in addition to receiving monthly motivational payments from the Global Fund project, would receive an additional 500 KGS for Internet. We also provided regional TB centers with connections. Besides this, we discovered a few districts where the order n225 wasn’t carried out at all, and through the regional TB centers we responded to this issue and increased patients’ access to VOT. For example, in the Issyk Kul region only 5 patients were on VOT, but by the end of May this increased to 20 patients.

This example shows that even with online / distance work, we are able to maintain control and timely adjust our work for the benefit of patients. 

A set of pills for TB treatment. Photo: Marion Biremon / TB Challenge project

Minimizing the negative impact of Covid-19

In these difficult conditions for the world and our country, we are looking for new methods to timely identify the needs and requirements of our partners and beneficiaries and appropriately respond to them.

Experts say that the Covid-19 pandemic will set the fight against TB several years back as regards to diagnosis and treatment. According to a survey conducted by the Stop TB Partnership, the London Imperial College and the Johns Hopkins University, 6.3 million people will develop TB in 2020-2025 due to the quarantine measures linked with Covid-19. The death of 1.4 million people will worsen the situation in this field to 5-8 years back. In Kyrgyzstan, since the beginning of the Covid-19 epidemic, the number of drug-resistant TB patients diagnosed dropped by more than two times. This means that every month, between 50 and 80 people do not start their treatment for drug-resistant TB and remain a source of infection.

Together with our partners we are making every effort to minimize the negative impact of the pandemic on our country. We are infinitely grateful to our partners – the Ministry of Health, the AIDS Center, the Republican Center for Addictions, the National TB Center, international projects and civil organizations – and to health care workers who are continuing their work and aren’t leaving patients without treatment or clients without services. We want to tell our patients and clients: keep fighting, each of you matters!  

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