Horse-riders, text messages and creative tracking systems improve TB detection in rural Lesotho
Lesotho, often referred to as the “Kingdom in the Sky”, is a small land-locked country surrounded by South Africa. With a population of just 2 million, the country has been combining novel technology and local solutions in the fight against tuberculosis (TB). Being 80% mountainous, and situated 1,800 meters above sea level, Lesotho is among the 49 least developed countries in the world, with an estimated 58% of the population living below the poverty line in 2008.
Lesotho has both the second highest incidence of TB (640 per 100,000) and the second highest HIV co-infection rate of adult TB cases in the world. In 2008, 76% of TB patients were also co-infected with HIV.
FIND has been working in Lesotho with the Ministry of Health and Social Welfare since 2007 and, together with other partners (WHO and Partners in Health), has actively contributed towards laboratory strengthening, as well as supporting the microscopy network through training and introduction of an external quality assurance programme. A TB culture and molecular facility has been established at the Central TB Reference Laboratory in the capital city of Maseru and a grant awarded by TB REACH in 2010 is expanding the project in a new direction, to combat the inaccessibility of diagnosis in rural Lesotho communities.
TB REACH is an initiative of the Stop TB Partnership financed by the Canadian Government, which promotes innovative approaches for early and improved TB case detection. TB REACH funding will improve access to timelier TB diagnosis and case follow-up for people living in remote, mountainous communities. Tuberculosis diagnosis is simply unavailable at most of the local health facilities used by the rural population, resulting in specimens being referred to far off analysis centres. This leads to delays in diagnosis because of the difficulties associated not only with specimen transport but also with the reporting of results via paper-based forms in areas where there is no regular postal service.
The TB REACH project encompasses 5 microscopy centres at district hospitals and 48 peripheral health centres, all located in four remote, mountainous districts (Mafeteng, Mohale’s Hoek, Quthing and Thaba Tseka). The main objectives are:
- to strengthen quality collection of sputum specimens for TB testing
- to strengthen rapid sputum transport systems for TB diagnosis
- to develop and implement an SMS (text message)-based system for sputum specimen tracking and results reporting to facilitate early TB detection
- to strengthen prompt treatment initiation and treatment monitoring under the National Tuberculosis Programme (NTP)
To meet these goals, FIND has trained more than 138 village health workers (VHWs), who have been deployed both at health centres and in their communities, to identify TB suspects and refer sputum specimens for TB testing, as well as to provide treatment support and act as a crucial link between the patient, community and the health system. A total of 46,349 people have been screened for TB and 1,994 (4%) have been identified as TB suspects and referred for TB testing. Village health workers have long been an important part of health care provision in Lesotho: since the 1970s, villagers in remote parts of the country have been assisting their communities, especially with respect to maternal and child health issues. More recently, the role of VHWs has been extended to include providing support to patients being treated for TB and HIV infections.
The problem of speciment transport is being improved by engaging horse riders in areas where communities have poor or no access to the nearest health centres. They work either seasonally or year round to collect sputum samples from health facilities and take them back to the more centrally located laboratories where microscopy is performed. The Basutho ponies are a traditional form of transport, and are well known for their hardiness and sure-footedness, as well as their docile temperament. These ponies are an integral part of life in the highlands of Lesotho and are the preferred (and sometimes only) means of transport for many villagers, especially in harsh weather conditions when roads can be inaccessible for long periods. In this way, local knowledge and traditions have directly facilitated roll-out of novel diagnostics and improved access to health care for some of the most isolated communities in Lesotho.
The SMS system has been developed by FIND for the identification of TB suspects, referral and testing of sputum specimens, and registration and monitoring of TB patients on treatment within the NTP. This system is based on the open-source RapidSMS framework and requires minimal investment in terms of hardware or devices for data entry. Health workers at the remote health centres use simple coded text messages for registering TB suspects and initiating patients on treatment, and receive patient results and alerts via SMS. When their results are ready, patients receive alerts via SMS, including reminders for checkups. Users at the laboratories and district TB programme officers/coordinators can access the system via a web-interface, receiving specimen results directly. They can also track patients during treatment, and receive alerts. Automated, real time reports have been developed to assist in monitoring programme performance on a real-time basis.
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