There was no answer at the door when Gulnara knocked and knocked. She’s been through this many time before: her patients, to whom she brings antituberculosis pills every day, don’t always greet her with a huge smile at first. TB treatment is long and difficult, and causes many side-effects, so patients don’t always want to take it. Especially those who have other problems to deal with.

But it’s Gulnara’s job to make sure that they take their pills every day, to support patients and help them solve any difficulties. So, she never gives up. That early morning, she found her patient, Roma, who has addiction problems on top of TB, in a park after asking his neighbors and relatives where he could have gone. They sat down and talked, and Roma took his pills, step-by-step fighting TB. At the end of the day, all the patients are grateful for Gulnara’s help. 

Bringing treatment to patient’s homes

Gulnara Barakova works as a case manager for the National Red Crescent Society’s (NRCS) TB project, funded by the UNDP / Global Fund. The four case managers of the project help non adherent and socially vulnerable patients in Bishkek city complete their TB treatment, as it’s the only way to ensure they will be cured and prevent further TB infections. 

When patients with tuberculosis are discharged from their hospital, they continue their treatment at home. They’re required to go to a health facility every day to take their pills in front of a nurse: this is important to ensure that they don’t skip a dose or a drug. And this for many months, up to two years for patients with drug-resistant TB. But for many, this becomes a real burden. Some patients don’t have the possibility to go to the health facility every day, especially during its opening hours. Since summer 2018, case managers bring pills to patients’ homes directly and every day if they are not able to go to the health facility themselves.

“We work with patients who need to receive treatment at home. These are patients with severe forms of TB, patients with co-infections (HIV, TB), patients with health problems like diabetes, patients with addictions, patients who have financial difficulties or small children, and non-adherent patients,” explains Viktoria Kanina, the TB project coordinator for the NRCS.

The best prevention: curing all patients

“The best prevention for TB is to ensure that every patient completes their treatment. But they’re not all able to do so, so we’re here to bring them their treatment at home, and to support them psychologically, socially and financially,” says Viktoria Kanina. Case managers work with patients in difficult situations, upon request of the Bishkek City TB Hospital and in regular contact with doctors. On top of providing daily treatment for these patients, the NRCS staff gives them support, vouchers, and clothes, educates patients and their relatives on TB, help them get monitored, report side-effects to their doctors, and often just become friends.

“It’s a very good project,” says Gulnara as she drives to her next patient’s home.

“They’re under our control and we see progress every month, we see that treatment helps them. Patients are very happy to receive this help. I know that without this project, some of my patients would have stopped treatment all together, others wouldn’t take it regularly, because they just can’t" - she said.

At the next house, she’s greeted by the laugh of a one-year-old boy. His mother Alina has three young children to look after. She’s diabetic and injects insulin five times a day, and now, she has to take more than a dozen pills too, to fight TB. “I used to be a social worker, then I fell sick with TB and had to stop working,” she says. “I don’t know if I would have continued treatment if Gulnara couldn’t come every day to bring me the pills. There’s no one to look after my children, I don’t have enough money to take the bus to the city center every day, and the pills make me sick, so the long ride is just too difficult.”

Less patients interrupt treatment

“Case management is very important. Before in Bishkek we had many patients, who stopped taking treatment. They couldn’t come to the hospital every day, and many don’t have enough knowledge on TB and don’t understand how important it is to complete treatment. We can’t end TB without case management,” says Sainagul Djanabilova. She works as a doctor at the Bishkek City TB Hospital, and after her shift as a case manager for patients in need.

This pilot project in Bishkek has proved to be very efficient: rates of TB patients lost-to-follow-up (ie, who have stopped treatment for two months or more) in the city dropped from 23% to around 4% only. In 18 months, the project case managers have worked with 145 patients.

Gulzat Kydyralieva also works as a case manager after her shift at the National TB Center. She spends time with her patients to know how they’re doing and if they have any problems and gives them information on TB. “We need to build a trustful, respectful, friendly and thankful relationship with the patients so that our work will be efficient,” she says. 

Gulzat tells the story of an old woman with TB who used to stay in bed all the time, “but now, she waits for me impatiently by the door and notices if I’m a couple of minutes late,” she laughs. Most of her patients are in difficult life situations and the help they receive is lifesaving. The UNDP / Global Fund gives 1000 KGS (14 USD) every month to patients on treatment for drug-resistant tuberculosis, and for many, this is their only source of income.

 “I’m so happy when a patient completes treatment or is able to continue taking it without me. I feel like I really helped someone,” says Gulzat as she sits behind her wheel and gets ready to visit another patient.