Combining tuberculosis treatment with nutritional support and sustainable income generating activities

My partner organization’s third department (in addition to craft production and hospitality services) is primarily focused on health, more specifically tuberculosis (TB) treatment and prevention.

TB is most often found in the lungs, making it an air born illness, often transmitted from one person to another through coughing or sneezing, particularly in poorly ventilated, crowded areas, and from repeated exposure to TB (when a close family member or partner is infected, for example). It is a serious problem in Namibia, and is deadly if left untreated.

TB is curable with proper, continuous treatment, which can last between six and twelve months. However when people do not take their medication regularly (daily), they can develop immunities to certain drugs, and the illness can evolve into a mulit-drug resistant (MDR) strain of TB, which becomes much more difficult to treat.

My partner organization’s impressive program stands on three main pillars: Community-based Direct Observation Treatment (CB-DOTS), a nutritional support program, and a craft training program.

The DOTS model brings treatment to the patients’ communities by setting up offices in different parts of the region: after starting two weeks of treatment in hospitals/clinics (after which the disease under treatment is no longer contagious), patients are referred to their closest ‘DOT point’, where they come each morning to take their medication, and receive counseling and support through a buddy system, where most (if not all) employees are former TB patients, encouraging existing patients to make it through treatment.

If a patient does not show up for their treatment, they are vigorously tracked down and given their medication and any other required support, which has lead to a 75% decrease in defaulters (people who do not successfully complete treatment) over the past four years.

To encourage patients to come to their local DOT point on their own, the nutritional support program provides simple, nutritional meals for them to take with their medication. This is an essential part of treatment for the most disadvantaged patients, whose bodies could not cope with the medication on an empty stomach.

The craft training program is an additional means of empowering and encouraging patients to complete treatment: they are taught to make wire/bead crafts, and when successfully cured of TB, they are then paid for all of the crafts they have produced. This model not only motivates patients to make it to the end of treatment for the financial incentive, but it also prevents them from using the money during treatment for common habits (mainly excessive drinking of alcohol) that would have a negative impact on their medication and comportment.

This program continues to run effectively, and to contribute to its future success and expansion, I was asked to contribute by helping out with a new donor grant proposal.

After participating in a brainstorming session for new ideas, and after reviewing more details about the current program, I recognized that the existing donor has a rigid set of guidelines to be followed when it comes to policies, procedures, and spending; this has a very positive effect on the operations of the department, as people know what they must do and how they must work in order to fulfill their funding obligations. I saw this new grant proposal as an opportunity to create similar systems that could improve working relations between the organization’s three departments, by guiding them to follow fair procedures and policies that are written into the proposal.

I already had some background understanding and ideas that I wanted to focus attention on: the simplest thing was to address challenges and friction that had come up repeatedly in management meetings without any resolution or compromise moving forward.

I held individual meetings with management from each department, listening to what benefits (for their specific department) they would like to see come out of a new grant. These ideas were compiled, researched, shared and transformed into a comprehensive program proposal entitled the ‘TB Secure Livelihoods Training and Empowerment Program’.

The specific purpose of this program is to expand on the existing TB program (which focuses on the decrease of defaulters during treatment), by also focusing on the prevention of TB re-infection in cured patients after treatment.

I created some questionnaires to be distributed to the different DOT points (seeing the patients every day makes it easy to acquire up-to-date information and statistics), and I found that 19% of our current patients were ex-patients who had been cured, then re-infected after treatment. At the same time, 52.2% of the 588 patients were unemployed, and another 6.5% underemployed. And of all the patients trained to make crafts during treatment, none of them remained connected to the organization after treatment, because there was no organized means of keeping in contact with them should craft work become available.

For the disadvantaged, these gaps often translate into a cycle of them contracting TB; coming to the DOT points for food security, treatment, and income generating activities; successful curing of TB and a one-time payment for crafts produced; a return to the same environment and circumstances they were in prior to treatment, with no food or income security; TB re-infection; dependence on the TB program to go through the cycle again; and again; and again.

To break this cycle, we developed a more sustainable training model, where patients would learn to make a variety of unique, marketable products during treatment (more in line with the quality of products made in the craft production department), with production organized into co-operative craft groups. Ex-patients could join after successful treatment and training, compensating them with a fair, monthly per-piece payment system, and a chance to earn income and change habits for the foreseeable future.

More entrepreneurial small-business skills would also be incorporated into workshop training, and those patients who express the initiative and desire to move forward with their own products would have access to the organization’s distribution network and support.

The organization’s craft production department would also benefit from this system: they (along with other sales outlets) could sell the new TB products on consignment, so that they (as well as the TB department and craft groups) have a clear understanding of how much profit they make from sales, and no products or excessive inventory are forced on anybody for sale. And the new products to be developed (during the first six months of the proposal) would compliment, not compete with, the existing craft products available from the craft production department.

At the same time, patients would be trained by craft production department staff to do the traditional embroidery and any other craft skills required by the craft department for some of the bigger orders they sometimes receive with tight deadlines; ex-patients with these skill sets would also be organized into specific craft groups, and when the craft production department needs assistance from outside groups, they could assign work to this new group, increasing speed, productivity, and income generating opportunities for both ex-patients and craft production department staff (who would be paid additional income as training workshop facilitators).

The hospitality department (that used to earn income from the preparation of food for the TB nutritional support program before funding was cut) would benefit by preparing an additional 4695 meals for training and workshops over an 18 month period, and by hosting a number of the workshops on their premises.

The finance manager crunched the numbers and budgets with me (including a scale back when the potential donor asked us to cut the budget in half), and he was also happy with the way we managed to allocate funds to areas that are not covered by the existing funding, ensuring that the new proposal truly compliments the existing donor funds, rather than duplicating them.

The general manager and TB manager gave their final changes and blessings before I had a good friend who is a translator/interpreter translate the document into the appropriate language of application. The potential donor has in turn enthusiastically submitted the proposal to the higher authorities, and whether or not it goes through, the systems and structure introduced could be implemented, with the potential to improve the opportunities and support network for thousands of the country’s most disadvantaged citizens.

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