Community-based tuberculosis care in Eastern Myanmar's chronic conflict zone: Challenges and solutions in meeting program objectives

In Eastern Myanmar, chronic conflict between the ruling military junta and ethnic minority groups has resulted in over 500,000 internally displaced persons (IDPs) with limited access to healthcare.  Tuberculosis (TB) remains largely unrecognized and untreated. To fill this gap, the Karen Department of Health and Welfare (KDHW), a community-based organization (CBO), implemented a TB control program (TBP) that operates independently of Myanmar's junta controlled national TB program (NTB).  Since 2007, KDHW has trained community health workers (CHWs) living among the target population in education, case-finding, laboratory diagnosis, and treatment of smear-positive TB patients using a DOTS approach.  Intensive bi-annual training and program modification using a process improvement approach were used to address numerous challenges, including military incursions, restricted communication between the clinic areas and KDHW headquarters, inability to coordinate care with Myanmar's NTB, as well as poverty, lack of community awareness, and difficult terrain. Using CHW feedback, KDHW program leadership developed solutions: provisions for dealing with program operations in unstable areas, simplified algorithms and monitoring instruments appropriate for CHWs, and program specific communication protocols.  Despite formidable challenges, over 20 CHWs completed advanced clinical and laboratory training. The CHWs have successfully educated and clinically screened over 20,000 IDPs, and have enrolled 35 patients. They achieved a treatment success rate of 96%, consistent with WHO standards. KDHW's experience demonstrates that a high quality CBO administered TBP can be implemented in a conflict setting where CHWs provide diagnosis and treatment.