In the thick of it: a three-month internship with the National Tuberculosis, Leprosy, and Lung Disease Program in Kenya
A brief account of myself, my PhD, and my internship in Kenya
My name is William Rudgard, and I’m currently a third year PhD student at the London School of Hygiene and Tropical Medicine. I’m particularly interested in ways to prevent people with tuberculosis (TB) from experiencing financial hardship because of their illness. Research shows that people with TB often face financial hardship because of having to pay for health services, and from not being able to work because of the illness.1 My PhD tries to show how governmental programs designed to reduce poverty and vulnerability might protect people with TB from experiencing financial hardship because of their illness. The case study for my PhD is focused on Brazil’s universal public health system called the Sistema Unico de Saude (SUS), and national programs such as the infamous Programa Bolsa Familia which have aimed to reduce national poverty and vulnerability.2,3 Evidence outlining the effect of these programs on TB control is slowly growing.4–6
My PhD is funded by the British Medical Research Council, and as part of my doctoral training I was encouraged to take a three-month internship outside of my usual studies.7 Always interested in how research is used in the policy making process, I wanted to spend my internship with a governmental or non-governmental institution involved with TB control, which was also interested in the provision of social protection to people with TB. During a conference in 2016, I saw that the Kenyan National Tuberculosis, Leprosy and Lung Disease Program (NTLD-P) was developing a social protection policy to prevent people with TB from facing financial hardship. This seemed like a perfect match.
During my PhD I have become part of an interdisciplinary research network called the “Health and Social Protection Action, Research, and Knowledge Sharing” (SPARKS) network, which aims to facilitate communication between prominent research institutions, public health practitioners, international organizations and civil society groups working in the field of social protection and health.8 Several members of the SPARKS network are program officers at the Kenyan NTLD-P. After a number of email exchanges, support from the head of the NTLD-P, and a successful application for funding to undertake the placement, I arrived in Nairobi in early January.
Situational analysis of TB, and healthcare delivery in Kenya
In 2015, Kenya was categorised as borderline to medium/low in terms of human development, and according to the World Bank, the country joined the league of lower-middle income country economies.8,9 In the same year, approximately forty-five percent of the population lived below the poverty line, and TB was one of the top-five causes of death (Figure 1).10,11 10,000 deaths were caused by TB alone, with a further 7,200 additional deaths caused due to a combination of HIV and TB. Although incidence of notified TB has been slowly decreasing since 2000, mortality rates have remained roughly the same. A TB prevalence survey in 2016 showed that approximately 60% of people with TB are notified in a given year.13 The Kenyan health sector is divided between a dominant public system, with major players including the Ministry of Health and parastatal organisations, and a well-developed private sector, which includes private for-profit, non-governmental, and faith-based facilities.14
Figure 1: Leading causes of death in Kenya. Source: Economic Survey – Kenya National Bureau of Statistics (KNBS)
January: The ‘ins and outs’ of writing a social protection policy for people with TB
After arriving in Nairobi I had to find my feet quickly. The first month of my internship was spent working on the NTLD-P’s social protection policy, and this gave me my first contact with evidence-based policy making. Last year the program conducted a county-wide cost survey in 30/47 counties to identify important drivers of household financial hardship related to TB. The results from the survey have helped the program prioritise specific interventions for inclusion in the social protection policy.
In line with previous knowledge, the survey showed that all patients are able to access TB medicines free of charge in Kenya. This is largely thanks to support from the Global Drug Facility for TB.15 However, the survey showed that health insurance is still needed to protect people from high expenses for consultation fees, chest x-ray, and hospitalisation. The survey also showed that people with TB report large expenses on food related to their illness. This is despite the program already providing undernourished patients (Body Mass Index (BMI) < 18.5) therapeutic feeds to help them gain weight. The program therefore recommended that food support should be targeted based on household food security, and be more oriented towards a take-home food ration. Finally, the survey showed that people with TB lose large numbers of productive work hours because of TB. To compensate for this, the program recommended that patients should receive monthly cash transfers during treatment.
To get feedback on the acceptability and feasibility of the interventions prioritised from the results of the cost survey, we scheduled meetings with key stakeholders, including the Kenya Stop TB Partnership, National AIDS Control Council (NACC), Kenya AIDS NGOs Consortium (KANCO), and Kenya Red Cross Society (KRCS). Some of the organisations were already implementing social protection initiatives. For example the KRCS recently launched a conditional cash transfer project in Turkana County (Figure 2) to address HIV risk amongst adolescents and young women aged between 15-24 years.16 During meetings, stakeholders gave valuable input on how the policy should be structured, and how they would be able to support its implementation. Learning from recent experiences by NACC, it was decided that a key annex for the policy would be a detailed investment case outlining the potential impact and cost-effectiveness of the policy. There is a push for the NTLD-P’s social protection policy to be implemented in collaboration with the Ministry of East African Community, Labour and Social Protection. Unfortunately, it was not possible to schedule a meeting with the Ministry, which highlighted the complexities of cross-sectoral collaboration for policy implementation.
Figure 2: County map of Kenya
February: Reviewing the performance of TB control activities across Kenya
In February, work on the social protection policy was interrupted by the program’s first performance review meeting. Scheduled bi-annually, performance review meetings are opportunities for the national program to review the performance of each of Kenya’s 47 counties in controlling TB. It was extremely interesting, and gave me an insight into the distinct challenges that each of the counties face in controlling TB. Many of the North Eastern counties of Kenya bordering Ethiopia and Somalia have to deal with large numbers of refugees, and the ongoing insecurities related to the Al Shabab extremist group. In the North West there are many issues related to drought, and disease surveillance in nomadic populations. In the coastal region, the high prevalence of HIV predisposes many people to TB, and requires a more elaborate and integrated response. Despite all these issues, it was impressive to see how most counties were maintaining high treatment success rates. Since the results of the 2016 national prevalence survey, showing an average case detection rate of 60%, a priority intervention for counties in the future will be active case-finding.
The meeting also showed that counties are making concerted efforts to enrol people with TB onto the National Hospital Insurance Fund (NHIF), which reimburses the greater part of any out of pocket expenses people have to make for outpatient and inpatient health services. Previous research in Kenya shows that many people identify advantages of pre-payment health insurance schemes like NHIF.17 However, there have also been reports of perceived poor quality of services at accredited facilities, inadequate benefit packages, and high co-payments.17 From an academic perspective, this first cohort of people with TB being enrolled onto NHIF represents a perfect opportunity to evaluate if and how NHIF helps prevent people paying high out-of-pocket expenses for TB services; and whether the services that are available through NHIF meet patients’ expectations. Such an evaluation would be a valuable part of any investment case that is put together to complement the program’s social protection policy.
Following the performance review meeting, my efforts were focused on the program’s next activity, namely its first quarterly review meeting of the year. In contrast to the performance review meeting, quarterly review meetings are an opportunity for the program to review the performance of sub-counties. I was part of the team reviewing the sub-counties in Turkana County, and Kisumu County (Figure 2). Turkana County is located in the northwest of the country and is very poor, whilst Kisumu County, is located in the southwest of the country and has lower than average levels of poverty.11 Kisumu and Turkana sub-counties notify approximately 50 cases per quarter, and as a result the meeting had more of a clinical focus compared to the performance review meeting that I had attended earlier in the month. There were often very rich discussions about specific cases, as sub-county representatives would be able to recall patient characteristics in detail. It was also interesting to see which interventions sub-counties used to achieve different TB control objectives. One especially interesting intervention was a cross-border initiative on communication and linkage to care that sub-counties in Turkana County were implementing in partnership with the KNCV TB foundation.18 The intervention focused on facilitating patient follow-up amongst mobile populations including nomads, pastoralists, and refugees.
During the meeting, I was struck by the consistently high proportion of patients reported as being undernourished at diagnosis (approximate range: 30%-90%). With this in mind, I also noted the consistently high treatment success rates reported across sub-counties. I knew that the NTLD-P provided therapeutic feed to people who were underweight at diagnosis (BMI < 18.5), and I became curious to know the extent to which this therapeutic feed helped people to successfully complete their treatment.
March: Building a case for evidence based decisions, and World TB Day
After the quarterly review meeting, I returned to Nairobi intent on trying to quantify the potential of therapeutic food support to improve TB treatment outcomes. A common tool used by the program for monitoring and evaluation is its electronic notification system TIBU, which in Kiswahili means “To Cure”. The TIBU platform, which was introduced in 2012, is reported to have greatly improved the monitoring and evaluation of TB control activities in Kenya. The notification system includes information on both receipt of food support (my proposed study exposure) and treatment success (cure or treatment completion), and death (my two proposed study outcomes). Other important characteristics recorded in the database include patient BMI at diagnosis, TB-HIV coinfection, region of treatment, and clinical vs. bacteriologically confirmed TB diagnosis.
After being granted access to TIBU data between 2015-2016, I began an analysis that compared treatment outcomes in people with TB who were recorded as either receiving or not receiving food support during treatment. Using statistical methods, I was able to account for differences between these groups (e.g. the proportion of people with TB/HIV confection) that might have explained an observed association between my exposure and outcome. To my surprise, my final results showed that receipt of food support was not associated with improved TB treatment outcomes, and was in fact associated with increased risk of death. With food support unlikely to cause death, this result might be due to not controlling for important demographic, socioeconomic and/or clinical factors that are not reported routinely in TIBU. For example, the TIBU notification system does not collect any socioeconomic information (e.g., pastoralism, family size, education or income) or detailed clinical characteristics (e.g., TB bacillary load). If poorer people were more likely to receive the food support, and also more likely to die, then the final association that I estimated might have been biased. The only way to test this would be to conduct a follow-up study.
The highlight of the three month internship came when I was able to present my findings to the program. For me, this represented an opportunity to fulfil my original interest to participate in an evidence-based decision making process. Following the presentation, the program officers expressed their own surprise at the results. Following further discussion of the inability of the routine data to account for patients’ socioeconomic characteristics, they were hesitant about making any actionable decisions regarding the provision of therapeutic feed to people with TB. Instead, thoughts focused on the need to conduct a follow-up study to better understand the relationship between therapeutic food support and treatment outcomes. It was decided that if it were to go ahead, the study should also incorporate a qualitative element to check patients’ acceptability and use of the therapeutic feed.
The final activity of my internship was attending the program’s World TB Day celebrations. This year the program had organised to hold the event at the Mathare Youth Sports Association (MYSA).19 Mathare is a collection of slums in Nairobi with a population of approximately 500,000 people. The day included a football tournament, accompanied by TB screening, HIV testing, public health education, and high-level speeches from guest speakers. The day’s celebrations were a vivid reminder of how important community based activities are for TB control, and hopefully represented a growing trend for more grassroots engagement in global TB control.
Closing remarks: Reflections on the internship
Looking back on my three months in Nairobi, the internship surpassed all of my expectations and enriched my PhD experience tremendously. It gave me a deeper understanding of the complexities of TB control, and strengthened my interest in operational research aimed at improving the delivery of existing services. The opportunity to analyse the NTLD-P’s data also improved my analytical skills, and demonstrated the potential of null results to positively contribute to an academic field.
By William Rudgard, PhD Student, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine.
- Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review. Eur Respir J. 2014;43(6):1763-1775. doi:10.1183/09031936.00193413
- Gazola Hellmann A. How Does Bolsa Familia Work? Best Practices in the Implementation of Conditional Cash Transfer Programs in Latin America and the Caribbean. Washington: Inter-American Development Bank; 2015. https://publications.iadb.org/bitstream/handle/11319/7210/How_does_Bolsa_Familia_Work.pdf?sequence=5&isAllowed=y. Accessed December 1, 2017.
- Couttolenc B, Gragnolati M, Lindelow M. Twenty Years of Health System Reform in Brazil : An Assessment of the Sistema Unico de Saude. Washington, DC: The World Bank; 2013. https://elibrary.worldbank.org/doi/pdf/10.1596/978-0-8213-9843-2. Accessed January 15, 2016.
- Torrens AW, Rasella D, Boccia D, et al. Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil. Trans R Soc Trop Med Hyg. 2016;110(3):199-206. doi:10.1093/trstmh/trw011
- Nery JS, Rodrigues LC, Rasella D, et al. Effect of Brazil’s conditional cash transfer programme on tuberculosis incidence. Int J Tuberc Lung Dis. 2017;21(7):790-796. doi:10.5588/ijtld.16.0599
- Rudgard WE, Chagas NS das, Gayoso R, et al. Uptake of governmental social protection and financial hardship during drug-resistant tuberculosis treatment in Rio de Janeiro, Brazil. Eur Respir J. 2018;51(3):1800274. doi:10.1183/13993003.00274-2018
- Medical Research Council. Studentships. https://mrc.ukri.org/skills-careers/studentships/. Published June 17, 2016. Accessed April 19, 2018.
- Health and Social Protection Action Research & Knowledge Sharing (SPARKS) Network -Rationale, Objectives and Work Plan. Geneva: WHO/HTM/TB; 2017.
- United Nations Development Programme. Human Development Reports, Table 1: Human Development Index and its components. http://hdr.undp.org/en/composite/HDI. Accessed April 19, 2018.
- The World Bank. World Bank Country and Lending Groups. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups. Accessed April 19, 2018.
- Kenya National Bureau of Statistics and Society for International Development. Exploring Kenya’s Inequality: Pulling Apart or Pooling Together. Nairobi, Kenya; 2013. http://inequalities.sidint.net/kenya/national/. Accessed March 25, 2018.
- Kenya National Bureau of Statistics. National Registered Deaths by Major Causes: 2010 – 2015. KNBS Open Data Portal. https://knbs.or.ke/visualizations/?page_id=4199. Published February 25, 2015. Accessed April 19, 2018.
- The National Tuberculosis Leprosy and Lung Disease – Program. Kenya Tuberculosis Prevalence Survey: Key Findings and Our Call to Action. https://www.chskenya.org/wp-content/uploads/2017/04/TB-Prevalence-Survey-Key-FIndings-Infographic.pdf.
- Muga R, Kizito P, Mbayah M, Gakuruh T. Overview of the health system in Kenya. http://www.measuredhs.com/pubs/pdf/SPA8/02Chapter2.pdf. Published 2005. Accessed April 20, 2018.
- Stop TB Partnership. Global Drug Facility (GDF) – What is the GDF. http://www.stoptb.org/gdf/whatis/default.asp. Accessed April 20, 2018.
- Cash transfers to benefit adolescents and young women in Turkana in the fight against HIV/AIDS. ReliefWeb. https://reliefweb.int/report/kenya/cash-transfers-benefit-adolescents-and-young-women-turkana-fight-against-hivaids. Accessed April 19, 2018.
- Mulupi S, Kirigia D, Chuma J. Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya. BMC Health Serv Res. 2013;13:474. doi:10.1186/1472-6963-13-474
- Introducing the East Africa Cross Border TB Initiative. KNCV – Tuberculosefonds. https://www.kncvtbc.org/en/2017/02/23/introducing-the-east-africa-cross-border-tb-initiative/. Published February 23, 2017. Accessed April 19, 2018.
- Mathare Youth Sports Association. MYSA. http://www.mysakenya.org/. Accessed April 19, 2018.