Health Surveillance and Disease Management / Communicable Diseases / Tuberculosis
Regional Meeting to Analyze Access to Antitubercular Treatment in Indigenous Populations(Panama City, 13–15 October 2004) | ||
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Aide-mémoire (in Spanish, PDF, 168 pp, 4 Mb, chapter headings translated below for user orientation) |
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Executive Summary | General Remarks, Pending Issues, and Recommendations In November 2004, for the very first time a Regional Meeting was held in Panama to analyze access to anti-TB in indigenous populations. PAHO, as organizer of the event, has documented the event, describing the main experiences, contributions, and conclusions of the delegations of the participating countries. The papers opening the event report on the relationship between the situation of tuberculosis in the indigenous populations in Latin America and the conditions of poverty and exclusion in which they live, to which are added the difficulties in the response of health services relative to limitations in supply, as well as the various interwoven cultural factors that imply a broad range of interpretations of and responses to the disease in each context. In this scenario, the DOTS Strategy has been recognized as the recommended WHO strategy for facing uberculosis effectively in the Region, as an alternative based on sound political, technical, and management principles adaptable to local conditions. To these are incorporated concepts and relationships between factors that affect access to drugs, which provide a framework for developing the analysis of the variables determining the access to treatment in each participating country. Knowledge of the TB situation in indigenous populations is affected by deficiencies in information systems and registries, even more so in the Amazon basin where difficulties in geographical access and the limited supply of all types of services place local indigenous population in conditions of even greater vulnerability to tuberculosis. In the experiences and innovations presented here, there can even be different strategies in a single country, with important lessons learned. Such variations are the implementation of shelters, a variety of ways to incorporate community health workers, different degrees of social participation in service management, options for integrating an intercultural approach and for integrating the strategy into local development processes. Other experiences, i.e. the IMCI strategy and the integration of a gender approach, provide valuable elements for optimizing the DOTS Strategy for applying it at the level of indigenous populations. The main lessons learned have to do with integrating an intercultural perspective, with social participation, with the sustainability of health services and of certain managerial and administrative elements of the strategy. Greater barriers are recognized in the area of the availability of drugs and services, and in geographical access to services, which in turn increase difficulties in financial accessibility. With all this input, the delegations of each country prepared their own workplan, where the contribution of the main factors discussed became clearly evident. The plans respond to the levels of implementation of the DOTS Strategy in each country, thus becoming a valuable contribution to the National Tuberculosis Programs. General Remarks, Pending Issues, and Recommendations This meeting provided a valuable opportunity for technical staff members and responsible personnel in the tuberculosis programs of several Latin American countries to analyze the epidemiology of tuberculosis in indigenous populations, share their experiences, and draft proposals geared towards increasing the access to treatment. Many needs arose to modify the strategies used to date. The group prepared that incorporated the main principles and strategies. These plans should be socialized and become concrete proposals for change and innovation on the basis of a firm, sustained political decisions. The entire Latin American Region should have information as complete as possible on their indigenous populations, with the greatest level of territorial disaggregation and with indicators on their health and living conditions. This information can escape the notice of public health institutions, making it necessary to coordinate with the national entities responsible for the development of indigenous peoples, state offices of national statistics, etc., for the purpose of exchanging the information that will make adequate service planning possible. This information can contribute data to prepare baselines prior to interventions, making it possible to evaluate their results and impact in the medium and long term. This baseline should have both qualitative and quantitative information with the highest level of possible geographical disaggregation and with indicators that include all ethnocultural references, information on age groups and gender, and information relevant for the optimal use of epidemiological information on tuberculosis. As can be seen throughout the country presentations, tuberculosis represents a serious public health problem among native peoples, and an approach is needed that extends beyond the health sector. Indigenous peoples have achieved a certain level of political representation in the majority of countries. Almost all the countries have government offices, and there have been moves to incorporate in their political and social agendas solutions to the type of vital problems that decrease any potential for development. This shows the need to hold international events such as this one with the participation of governments, organizations, and indigenous movements, with the goal of making joint commitments for definitive tuberculosis control among indigenous peoples. The organizational potential and the principles of solidarity, cooperation, and reciprocity that characterize the vast majority of indigenous community processes can be activated through a concerted effort and a popular to take co-responsibility in this area. Along the same lines, both local actors and governments have an important role in addressing tuberculosis and the implementation of the DOTS strategy. Local participation in carrying it out and in adapting the strategical components to local geographical and cultural conditions is essential for any success in increasing access to diagnosis and treatment, mainly among scattered populations. However, it should be taken into account that the DOTS strategy needs to respond to a national policy of TB control, a public health policy that-although it should be adapted to local condition-should nonetheless remain as a national policy whose financial and technical responsibility rests with the Central State and should be carried out in coordination with the local governments. Miscellaneous experiences sustain access to treatment through community agents. It is important to design of the last link in the chain of the strategy in every locality. There have been successful experiences in community health workers strictly supervising treatment, but this needs a monitoring system and very well-designed supervision carried out by the local health services. This should be accompanied by logistics and management systems of adequate for each geographical area that ensure the desired conditions, so the drugs and services are available, geographical barriers overcome, and strict supervision of treatment effectively carried out. The costs of accommodation for patients, even more so with families, are always going to be high; and how long they stay can generate difficulties in adherence to treatment. These budgets can be transferred to the implementation of logistical strategies to deal with the operating expenses of community agents who strictly supervise patient treatment. The increase in the incidence of HIV infection in indigenous population was only mentioned in the presentation from Venezuela; however, the fact that such infection is characteristically underreported should be taken into consideration when planning interventions for timely detection of co-infection. This also implies a new challenge for public health: it should not take a long time to propose discussions and actively search for alternatives, since the growth rate of the HIV epidemic demands it. Although it is obvious and redundant to insist on economic determinants, the investment needed for a strategy of strictly supervised treatment can articulated with other initiatives and interventions necessary in this area, both by the efficient optimization resources and by the huge and varied needs of these populations. |
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