**Final Report**

**for**

**Contract No. 200-2001-00121**

**Task Order No. 8**

***"*Evaluation of the US-Mexico Binational TB Referral and Case
Management Project*"***

**Submitted To:**

**Maureen Wilce**

**Department of Health and Human Services**

**Centers for Disease Control and Prevention**

**Office of Program Planning and Evaluation**

**July 20, 2006**

**Submitted By:**

**Mary Odell Butler, Ph.D.**

**Project Director**

**Rodolfo Matos, MA**

**Kendra Versendaal, MPH**

![](media/image1.png){width="1.5833333333333333in"
height="0.4131944444444444in"}

**Centers for Public Health Research and Evaluation**

**2101 Wilson Boulevard, Suite 800**

**Arlington, Virginia 22201**

*This report is work prepared for the United States Government by
Battelle. In no event shall either the United States Government or
Battelle have any responsibility or liability for any consequences of
any use, misuse, inability to use, or reliance on the information
contained herein, nor does either warrant or otherwise represent in any
way the accuracy, adequacy, efficacy, or applicability of the contents
hereof*

# EXECUTIVE SUMMARY

+-------------------------------+--------------------------------------+
| ## Title:                     | > Evaluation of the US-Mexico        |
|                               | > Binational TB Referral and Case    |
|                               | > Management Project                 |
+-------------------------------+--------------------------------------+
| ##                            | > 200-2001-00121, Task Order 8       |
|                               |                                      |
| ## CDC Contract Number:       |                                      |
+-------------------------------+--------------------------------------+
| ## Sponsor:                   | > Division of Tuberculosis           |
|                               | > Elimination                        |
|                               | >                                    |
|                               | > National Center for HIV,STD and TB |
|                               | > Prevention                         |
|                               | >                                    |
|                               | > Centers for Disease Control and    |
|                               | > Prevention                         |
|                               | >                                    |
|                               | > 4770 Buford Hwy NE, Mailstop K-22  |
|                               | >                                    |
|                               | > Atlanta, GA 30341                  |
+-------------------------------+--------------------------------------+
| ##                            | > Battelle Memorial Institute        |
|                               | >                                    |
| ##                            | > Centers for Public Health Research |
| Contractor's Name And Address | > and Evaluation                     |
|                               | >                                    |
|                               | > 2101 Wilson Boulevard, Suite 800   |
|                               | >                                    |
|                               | > Arlington, Virginia 22201          |
+-------------------------------+--------------------------------------+

## (pp. 1-3) I. Statement of the Problem

This report summarizes a Battelle project to evaluate "The US Mexico
Binational TB Referral and Case Management Project" in collaboration
with the Division of Tuberculosis Elimination, CDC and a Binational team
of evaluators. The goals of this evaluation were to assess the
feasibility, effectiveness, and value of the U.S.-Mexico Binational
Tuberculosis Referral and Case Management Project (Pilot Project).

The Pilot Project was initiated in 2003 by CDC in partnership with the
National Tuberculosis Program (NTP) in Mexico with the goal of building
a system to ensure continuity of care for tuberculosis patients who
crossed the US-Mexico border regardless of their immigration status. In
each country, providers used the Pilot Project referral systems to
register eligible patients in a central database (one database in the
U.S. and one in Mexico) and provide essential data about their
treatment. Providers notify the referral system on own their side of the
border when patients anticipate a move to another location. The referral
system then forwards treatment information to the referral agency on the
other side of the border, which in turn notifies a TB care provider in
the destination location, promoting continuity of care. A Binational
Health Card bearing a toll-free telephone number, to be carried by the
participating patients, complements the referral network and facilitates
patient access to the referral network from either side of the border.
The Card does not bear the patient's name, but has a unique identifying
number used by providers and referral agencies for tracking purposes.

The initial pilot sites included San Diego and El Paso/Las Cruces on the
U.S. side, and Tijuana and Ciudad Juarez on the Mexican side. During the
first year of implementation, the following sites were added: Webb and
Cameron County (Texas), the city of Chicago, and the States of Arizona,
Tennessee, and Washington on the U.S. side; Matamoros, Tamaulipas, and
the States of Coahuila, Nuevo Leon and Sonora on the Mexican side.

## (pp. 4-6) II. Evaluative Objectives

The specific objectives of the evaluation of the Pilot Project were to:

-   Document the processes and procedures developed to implement the
    Pilot Project;

-   Provide information to modify and enhance on-going Pilot Project
    operations, thus improving the program as it develops;

-   Assess whether the Binational referral system is effective at
    improving continuity of care and completion of therapy by patients
    who travel across the U.S./Mexico border; and

-   Determine the cost of implementing the Binational referral system.

Battelle's role in this evaluation was to provide evaluation expertise
to the Pilot Project Evaluation Work Group around evaluation design and
implementation, and to conduct data collection from Pilot Project staff,
health care workers, participating patients and policy makers in the US
and Mexico. CDC assumed responsibility for quantitative and qualitative
data analysis. Battelle worked with CDC to develop findings and
conclusions and to report these to the stakeholders. In addition,
Battelle was responsible for an evaluation of the political will to
support the project among public health policy makers in the United
States and Mexico.

The results of the overall evaluation were presented to the Binational
public health community at a World TB Day conference held in El Paso,
Texas on April 4, 2005. The primary purpose of this report is to
summarize the results of the evaluation of policy maker perspectives on
the Pilot Project. However, this will be contextualized in the very rich
data that were produced as a result of this broadly collaborative
project.

##  (pp. 7-13) III. Methodology

The sponsors of the Pilot Project adopted an evaluative perspective
throughout the design of the initiative following the general steps of
the CDC's Framework for Program Evaluation in Public Health. An
Evaluation Work Group was established at the inception of the project
and a logic model mapping how the project was expected to achieve its
objectives was developed. The Evaluation Work Group specified the
evaluation questions to be addressed. Data collection strategies
included aggregation of data from the Epi-TB, TIMS, Cure TB, and Mexican
NTP Card databases; site visits completed by Battelle with CDC and NTP
staff; interviews with key stakeholders; focus groups with patients and
health care workers; document reviews; and, cost data abstraction.
Battelle was responsible for designing and conducting all interviews and
focus groups and with completing the analysis of the stakeholder
interviews. The remaining activities were conducted by CDC.

Interviews with key stakeholders at the local, state and federal levels
in both the United States and Mexico were conducted by Battelle during
site visits to the border as well as to Washington, Mexico City and
Atlanta. Interviews were conducted from an instrument incorporating the
evaluation questions, but tailored to address the individual
perspectives of the respondents. A snowball sampling process was used to
identify the key stakeholders. Interviews were conducted in Spanish or
English, depending on the participant's preference.

Both interviews and focus groups with staff and patients were conducted
with staff at local health departments in San Diego, Tijuana, El Paso
and Ciudad Juarez during two site visits to each of these cities. In
addition, we visited ICE detention facilities in El Paso and San Diego
to discuss the experience of staff with the Pilot Project, their
perspective on how well it operated and barriers that they encountered,
issues surrounding the transmission and use of clinical information and
the training that they had received on the Pilot Project. A local
liaison was asked to identify health care workers involved with issuing
and tracking Binational cards and invite them to participate in the
focus groups. A series of open-ended questions were asked based on
themes identified by the evaluation design group. Some questions were
tailored to the specifics of the site.

Focus groups were conducted with between 2 and 9 patients during site
visits to San Diego, Tijuana, El Paso, and Ciudad Juarez. In addition, a
small number of telephone interviews were attempted with patients who
were lost to follow-up to determine reasons for incomplete referrals.
Card-holding patients at participating sites were recruited into focus
groups and asked a series of open-ended questions based on themes
identified by the evaluation design group. All focus groups discussions
were conducted in Spanish. Patients were provided with a cash incentive
for their participation in focus groups.

All focus groups were audio taped and transcribed. Notes taken during
the focus groups were used to cross check accuracy. The analysis of both
interviews and focus groups was completed by CDC staff from transcripts
that had been de-identified by Battelle. Content analysis, which allows
researchers to make inferences from qualitative data, will be used to
analyze responses to stakeholder interview question. With this
technique, a large amount of qualitative information could be reduced to
a series of variables that can be examined for relationships. Data were
coded and transcribed into Atlas-ti software for the content analysis.

## (pp.14-16) IV. Major Findings and Recommendations

***Political Will***. The key stakeholders were committed to the project
and wanted to see it continue, although many had questions about how
this would happen. From a public health perspective, policy makers in
both countries were interested in extending the Pilot Project beyond the
border area, citing limited benefits for the population that remains in
the border area. They indicated that a referral system was already in
place for these patients before the Binational Card program was
established and they saw little need for the Card program for these
patients. However, they felt that the card might be beneficial for
patients who move beyond the border.

There was abundant evidence from key stakeholders that the effective
collaboration between health officials in the US and Mexico is a very
important outcome of the Pilot Project for them. Key stakeholders also
felt that another positive impact of the project has been that both
countries have gained a better understanding of migration patterns
within their own countries and between the two countries.

***Role of the Binational Projects In The Border Area.*** The key
stakeholders overall felt that the Pilot Project makes an important
contribution to the continuity of care for patients along the border.
Those on the Mexican side were emphatic about the positive role of the
project in TB control and would like to see it expanded to other parts
of Mexico in order to facilitate referrals within the country. One very
important benefit of the Pilot Project in terms of TB control in the
border was that it asked no questions of patients about their
immigration status, thus giving health officials a chance to bring
infected TB patients to treatment regardless of their immigration
status.

***Cross-border Communication***. The Pilot Project required ongoing
dialogue across the border to reconcile different perspectives about
almost all aspects of the project. Thus, an understanding of the
conditions prevailing in the border area was essential to the Pilot
Project.

Two difficulties with data flow were mentioned in the stakeholder
interviews: an early misunderstanding of the data management roles of
various partner organizations (resolved with a negotiated division of
labor) and slow data flow within Mexico. Case reporting and data
management are much more centralized in Mexico than that in the US
requiring some time for data to move through required channels. Also
there is a lack of resources at the health centers and it is hard to
provide computers to all of them. .

Developing cooperation with immigration authorities around screening,
referral and treatment of TB patients in detention facilities was an
important achievement of the Pilot Project. The TB Pilot Project was
formally integrated into the detainee screening process and into the job
responsibilities of the health care staff in the Immigration Control and
Enforcement (ICE) facilities. It appears that the process worked
effectively, due to both formal integration of the Pilot Project into
their operations and the concrete support provided by Pilot Project
staff.

***Patients' Perspective And Opinion.*** The patients in the focus
groups liked the card because it allowed them obtain and continue
treatment while moving between healthcare clinics on both sides of the
border. There was anecdotal evidence that possession of a Binational
card improved TB treatment even in cities that were not part of the
Pilot Project. As expected, patients lost to follow up were extremely
difficult to contact. Of the four patients reached, two reported that
they had finished their TB treatment at sites that do not participate in
the Binational Pilot Project.

In sum, The Pilot Project went well in spite of a number of start up
difficulties and a few problems that were never resolved, and perhaps
cannot be resolved. The slow data flow in Mexico reduced the usefulness
of the data to health providers who were operating TB control programs
in the border. The labor burden imposed on public health staff was
acceptable in a Pilot Project but would need to be addressed in a more
systematic way for the project to be replicated elsewhere and sustained.
However, by and large the project was a model for effective and
productive collaboration of a large number of organizations across the
US-Mexico border, extending even to the federal level in both countries.
As our informants told us, the Pilot Project demonstrated what can be
done. This is in no small part due to the unceasing effort on the part
of CDC and the NTP in Mexico to promote ongoing meetings and discussions
of the Pilot Project, its successes and its struggles, broadly among a
large number of organizations. The commitment of the partners to this
project was notable, extending even to their active participation in the
evaluation.

The cost of any potential replication of the Pilot Project was a concern
for many stakeholders, including: burden on staff, direct costs of the
program and indirect costs of identifying and treating TB patients.
Policy makers in Mexico said that there was simply unlike to be
additional money for this project given other priorities. Even in the
United States that was some uncertainty about the economic viability of
finding and identifying new cases of tuberculosis without adequate
funding to expand treatment services.

## Recommendations

The following recommendations were made by more than one key
stakeholder:

***Expand the Pilot Project**.* There was wide agreement among key
stakeholders that CDC should continue and expand the Pilot Project, both
to other areas and to other agencies, to other institutions and other
diseases. A more extensive network should be created across the border
and across the participating states. The project should be expanded not
only to all the border cities, but to lower states in Mexico from which
many patients with TB in the border originate. Within Mexico, the
project should be expanded institutionally to include TB patients in
other parts of the Mexican health system.

***Publicize the Purpose and Achievements of the Pilot Project**.* There
needs to be better dissemination of information about TB itself, what
the Pilot Project is doing and the benefits of it to the health of the
population. Awareness of the project needs to be raised at the Federal
level in both countries as well as at the local level. One person
suggested that mass media marketing may be too costly, but local
marketing -- in newspapers, local radio, and signage -- is more
reasonable and reaches many people.

***Coordinate the Card with All Involved Agencies***. Those who operate
the project in the future might identify opportunities for collaboration
with organizations that have experience working with legal issues around
immigration status. All non-government organizations involved in the
project should coordinate to help protect the confidentiality of
patients. Operationally, it was recommended that cooperating agencies
have designated contact coordinators and that they be referred to Pilot
Project staff for technical assistance on a regular basis or as needed.

***Involve Staff at the Operational Level**.* There was some concern
that staff who are directly involved in implementing TB prevention and
control programs (providers, case workers, outreach staff) were not
involved in early project activities, including training. All staff
working at the level of program operations should be trained in
procedures involved in issuing and tracking Card patients and provided
with technical assistance thereafter. To facilitate this, Pilot Project
administrators should work with localities and jurisdictions to
understand their capacity and their needs relative to the operation of
the Pilot Project.

***Change Criteria for Card Eligibility**.* The Pilot Project procedures
specify that the care should be given only to TB patients who plan to
migrate. However, some health officials do not feel that this is a
reliable criterion for eligibility. Some argued that the card should be
given to all TB patients on the assumption that all are potential
migrants.

***Improved Communication.*** Good collaboration and communication is
essential in a project of this organizational complexity. Interviewees
called for better inter-jurisdictional communication. Perspectives of
the health care staff need to be known and considered. Different
perspectives from different participants, for example CureTB and TBNet,
need to be taken into account and reconciled.

***Utilization of Evaluation***. Interviewees considered ways in which
evaluation can be used to improve the program. They were especially
interested in ways to assess infrastructure and understand capacity, a
recommendation that will be especially important if the Pilot Project is
expanded to other jurisdictions.

***Funding.*** A majority of stakeholders interviewed volunteered that
funding of the Pilot Project is inadequate to sustain the program on an
ongoing basis. One person said, "The project should be funded adequately
to be implemented properly. This implies funding for treatment,
infrastructure, education and staff." Other program areas mentioned as
needing increased funding were improved communications, additional
support of fieldwork and bringing in other states or sites.

# Introduction and Background

This report summarizes a Battelle project to evaluate "The US Mexico
Binational TB Referral and Case Management Project" in collaboration
with the Division of Tuberculosis Elimination, CDC and a Binational team
of evaluators. The goals of this evaluation were to assess the
feasibility, effectiveness, and value of the U.S.-Mexico Binational
Tuberculosis Referral and Case Management Project (Pilot Project). The
specific objectives of the evaluation were to:

-   Document the processes and procedures developed to implement the
    Pilot Project;

-   Provide information to modify and enhance on-going Pilot Project
    operations, thus improving the program as it develops;

-   Assess whether the Binational referral system is effective at
    improving continuity of care and completion of therapy by patients
    who travel across the U.S./Mexico border, and

-   Determine the cost of implementing the Binational referral system.

Battelle's role in this evaluation was to provide evaluation expertise
to the Pilot Project Evaluation Work Group around evaluation design and
implementation, and to conduct data collection from Pilot Project staff,
health care workers, participating patients and policy makers in the US
and Mexico. CDC assumed responsibility for quantitative and qualitative
data analysis. Battelle worked with CDC to develop findings and
conclusions and to report these to the stakeholders. In addition,
Battelle was responsible for an evaluation of the political will to
support the project among public health policy makers in the United
States and Mexico.

The results of the overall evaluation were presented to the Binational
public health community at a World TB Day conference held in El Paso,
Texas on April 4, 2005. The primary purpose of this report is to
summarize the results of the evaluation from the perspective of health
policy makers. However, this will be contextualized in the very rich
data that were produced as a result of this broadly collaborative
project.

## Tuberculosis in the US-Mexico Border

TB is a serious, highly infectious disease with an airborne route of
transmission that disproportionately affects those of low socioeconomic
status, crowded living conditions and poor nutrition. The elimination of
tuberculosis in the United States depends heavily on preventing,
detecting, and controlling tuberculosis in foreign-born populations.[^1]
Prevention and control of tuberculosis involves identifying, diagnosing
and treating active cases of TB; and targeted identification, tuberculin
skin testing (TST) and treatment of TST-positive persons who are likely
to progress to active disease (e.g., recent contacts of TB cases, those
co-infected with HIV, immuno-suppressed persons and others determined to
be at high risk of exposure to TB).[^2] Tuberculosis treatment is labor
intensive, extending from six to twelve months in duration and requiring
frequent doses of medication. Treatment failure not only results in a
resurgence of symptomatic infectious disease, but selects for the
development of drug-resistant forms of *Mycobacterium tuberculosis*.
Because of the high cost of treatment failure, the most fail-safe method
of control is directly observed therapy (DOT) in which a health worker
observes patients taking their medication. Effective public health
action against tuberculosis thus requires case management, reliable
referral, and good data systems to monitor cases, ensure delivery of
treatment and detect loss of cases to follow-up.

Tuberculosis is a special public health concern in the US-Mexico border
area because many infected people move frequently across international
boundaries with different health systems and are difficult to track for
continued treatment. It is estimated that about 1 million persons cross
the US-Mexico border daily between California, Arizona, New Mexico and
Texas on the US side and Baja California, Sonora, Chihuahua, Coahuila,
Nuevo Leon and Tamaulipas on the Mexican side. This area is
characterized by a high incidence of TB, higher than the average for
either country. Based on 1997 data, the case rate per 100,000 population
can be calculated as 9.0 for four US border states (compared to 7.4 for
the United States) and 34.7 per 100,000 for the Mexican border states
(compared to 24.8 for all of Mexico).[^3] MMWR data published in 1998
showed that 18% of Mexican border cases are resistant to isoniazid and
another 6% are multi-drug resistant.[^4]

## The US Mexico Binational TB Referral and Case Management Project

The Pilot Project was initiated in 2003 by CDC in partnership with the
National Tuberculosis Program (NTP) in Mexico with the goal of building
a system to ensure continuity of care for tuberculosis patients who
crossed the US-Mexico border regardless of their immigration status. In
each country, providers used the Pilot Project referral systems to
register eligible patients in a central database (one database in the
U.S. and one in Mexico) and provide essential data about their
treatment. Providers notify the referral system on own their side of the
border when patients anticipate a move to another location. The referral
system then forwards treatment information to the referral agency on the
other side of the border, which in turn notifies a TB care provider in
the destination location, promoting continuity of care. A Binational
Health Card bearing a toll-free telephone number, to be carried by the
participating patients, complements the referral network and facilitates
patient access to the referral network from either side of the border.
The Card does not bear the patient's name, but has a unique identifying
number used by providers and referral agencies for tracking purposes.

The Pilot Project included a tracking and surveillance system based on
the characteristics of good public health and the specific
characteristics of TB case management in a population with the unique
characteristics of the border populations, i.e., linguistic and cultural
diversity, and mobility within a multinational jurisdiction. It built
upon collaboration across the border for TB control that is well
established in the border region. Several projects were already
operating in the border area, many of which became part of the Pilot
Project. CureTB, the organization that became the clearing house for
data under the Pilot Project, had been operating in San Diego since
1997. Cure-TB ran the Binational Tuberculosis Referral Program, operated
by the San Diego Health Department and provided data management for the
entire project. Implementation of the project in El Paso/Las Cruces,
NM/Cuidad Juarez, Mexico was facilitated by the Binational/Migrant
Tuberculosis Tracking and Referral Project (TBNet), a project of the
Migrant Clinicians Network. The Migrant Clinicians Network (MCN) has
long been involved in identifying and reporting TB cases including
national and international ones. The TB card gave then a method for
connecting to populations that are mobile at the state and federal
level. JUNTOS was an existing Binational project receiving funds from
CDC, State Health Department and the El Paso Health department to track
and refer cases of TB across the border in El Paso-Ciudad Juarez, a
function that they continued as part of the Pilot Project. Although
JUNTOS has followed TB cases on both sides of the border for some time,
it was helpful for them to have Mexican side put pressure on
participants in the Pilot Project for follow-up in Mexico. Many other
Partners were involved in support of the Pilot Project.

The initial pilot sites included San Diego and El Paso/Las Cruces on the
U.S. side, and Tijuana and Ciudad Juarez on the Mexican side. During the
first year of implementation, the following sites were added: Webb and
Cameron County (Texas), the city of Chicago, and the States of Arizona,
Tennessee, and Washington on the U.S. side; Matamoros, Tamaulipas, and
the States of Coahuila, Nuevo Leon and Sonora on the Mexican side.

## Organization of the Report

This report is organized in four sections. Following this introductory
section, we present the evaluation methodology in Section 2. Section 3
summarizes the findings of the evaluation of political will based on
interviews with health policy makers in the United States and Mexico.
Section 4.0 presents the conclusions and summarizes recommendations of
stakeholders for next steps in Pilot Project.

# 2.0 EVALUATION Methodology {#evaluation-methodology .unnumbered}

The sponsors of the Pilot Project adopted an evaluative perspective
throughout the design of the initiative following the general steps of
the CDC's Framework for Program Evaluation in Public Health. An
Evaluation Work Group was established at the inception of the project
and a logic model mapping how the project was expected to achieve its
objectives was developed. Evaluation was ongoing throughout the Pilot
Project, permitting partners to monitor the effectiveness of the
referral procedures and to allow project modifications to be implemented
in a timely manner. Evaluation activities were intended to directly
complement program implementation. Since program inception, the Pilot
Project sites have been self-evaluating their activities on an on-going
basis. For example, monthly Binational telephone conference calls,
involving a wide array of stakeholders were held. During these calls,
the sites report on the number of Cards distributed and the movements of
Card patients, with a view to reconciling the information held by the
sites and the referral agencies on both sides of the border.
Additionally the conference calls provided an opportunity for
participants in the Pilot Project to share experience and to discuss
emerging issues.

In addition to the self-evaluation, the Pilot Project was assessed in a
more formal evaluation designed to expand the scope of the
self-evaluation by performing advanced analysis on selected elements
from the data system, assess implementation and outcomes of the project
across all sites, and collect additional information, including
qualitative data for a comprehensive picture of the entire initiative.

## 2.1 Evaluation Design

The evaluation was planned in two phases. Phase I began when the Pilot
Project became operational, and provided baseline information about the
project and start-up issues. During Phase I, the monthly conference
calls were established. Additionally during Phase I, CDC and NTP staff
visited sites in El Paso-Cuidad Juarez and San Diego-Tijuana to compile
baseline data and identify barriers to Pilot Project implementation. The
reports from these site visits became an important resource for the
Phase II evaluation. Findings from Phase I were used to identify
evaluation topics to be explored in Phase II, and to inform the data
collection instruments and strategies used in Phase II. Battelle was
brought onto the Evaluation Team at the beginning of Phase II,

The Evaluation Work Group specified the evaluation questions to be
addressed and decided on the following data collection strategies:

-   Aggregation of data from the Epi-TB, TIMS, Cure TB, and Mexican NTP
    Card databases;

-   Site visits completed by CDC and NTP staff;

-   Interviews with key stakeholders;

-   Focus groups with patients;

-   Focus groups with health care workers;

-   Document reviews; and,

-   Cost data abstraction

To reduce the burden of the evaluation to Pilot Project participants,
many of these activities were conducted simultaneously. Battelle was
responsible for designing and conducting all interviews and focus groups
and with completing the analysis of the stakeholder interviews. The
remaining activities were conducted by CDC. This report is based only on
the activities that were conducted by Battelle. The Evaluation Questions
that guided this evaluation are shown in Appendix B.

## 2.2 Interviews with Key Stakeholders 

Interviews with key stakeholders at the local, state and federal levels
in both the United States and Mexico were conducted by Battelle during
site visits to the border as well as to Washington, Mexico City and
Atlanta. Topics covered in these interviews included:

-   Political will to support Pilot Project activities,

-   Role of the Binational Projects in TB control as well as broader
    protection of public health in the border area

-   Coordination of tuberculosis prevention and control with immigration
    authorities, jails/prisons and rehabilitation centers

-   In-country data flows and data systems

-   Cross-country data flows and communication

Key stakeholder interviews were conducted to obtain information
pertinent to the evaluation topics. Interviews were conducted from an
instrument incorporating the issues above, but were tailored to address
the individual perspectives of the respondents. For example, staff from
CDC and NTP were asked about their perspective regarding the
coordination required to implement a project that spans two countries
with different public health infrastructures and norms, while
state-level staff will be interviewed about the changes brought about by
the Pilot Project in the ways in which they interact with their
counterparts across the border.

These interviews were conducted by Battelle to ensure an outside
perspective. A snowball sampling process was used to identify the key
stakeholders. Battelle began by interviewing known key partners already
known to the project. As part of this interview, respondents were asked
for referrals to others who should also be interviewed.

Battelle recruited potential respondents and set up appointments with
individuals. Potential participants were approached, usually by
telephone and invited to participate in the interview. This first
contact was followed with a letter providing a brief introduction to the
evaluation and explaining its purpose and procedures. Interviews took
place at a convenient time for the respondent either during a site visit
or by telephone. Interviews were conducted in Spanish or English,
depending on the participant's preference. The privacy of the
respondents and the information that they provided was protected
throughout the data collection and analysis processes and in reporting
of the data.

## 2.3 Focus Groups and Interviews with Patients  {#focus-groups-and-interviews-with-patients .unnumbered}

To understand the patient's perspective on the Binational cards, the
referral experience and their experience at their destinations, focus
groups were conducted with between 2 and 9 patients during site visits
to San Diego, Tijuana, El Paso, and Ciudad Juarez. In addition, a small
number of telephone interviews were attempted with patients who were
lost to follow-up to determine reasons for incomplete referrals.

Card-holding patients at participating sites were recruited into focus
groups and asked a series of open-ended questions based on themes
identified by the evaluation design group. Focus group questions were
tailored to each site and population group based on findings from Phase
I. For example, patients in El Paso were asked about local clinical
services (i.e., the Tillman clinic), and about the role JUNTOS may play
in their care. All focus groups were recorded on audiotapes which were
then transcribed. Notes taken during the focus groups were used to cross
check accuracy. All focus groups discussions were conducted in Spanish.
Patients were provided with a cash incentive for their participation in
focus groups.

Patients lost to follow up were contacted based on information provided
to Battelle by the Pilot Project Coordinator at Cure-TB. Because of the
need to attempt to trace these patients, Battelle was provided with the
patient name and last known contact information. Of fifteen patients
recommended for these interviews, telephone interviews were completed
with only three interviews were completed, all in Spanish. Patients were
paid an incentive for these interviews.

## 2.4 Focus groups and interviews with staff at local health departments {#focus-groups-and-interviews-with-staff-at-local-health-departments .unnumbered}

To obtain a wide range of information on health care worker perceptions
about the Card and Binational system, Battelle conducted both interviews
and focus groups with staff at local health departments in San Diego,
Tijuana, El Paso and Ciudad Juarez during two site visits to each of
these cities. In addition, we visited ICE detention facilities in El
Paso and San Diego to discuss the experience of staff with the Pilot
Project, their perspective on how well it operated and barriers that
they encountered, issues surrounding the transmission and use of
clinical information and the training that they had received on the
Pilot Project procedures.

Local health care workers who were involved with the Pilot Project at
participating sites were recruited for interviews or focus groups. A
local liaison was asked to identify health care workers involved with
issuing and tracking Binational cards and invite them to participate. A
series of open-ended questions were asked based on themes identified by
the evaluation design group. Some questions were tailored to the
specifics of the site. For example, staff in San Diego were about how
their activities mesh with other border health initiatives. In Juarez,
they were asked about their coordination with JUNTOS. The focus groups
discussions were conducted in English or Spanish as appropriate. The
discussions were facilitated by Battelle to protect the confidentiality
of the respondents. Participation in this data collection was completely
voluntary for staff and only Battelle knew who participated and who did
not.

## 2.5 Qualitative Data Management and Data Analysis {#qualitative-data-management-and-data-analysis .unnumbered}

All focus groups were audio taped and transcribed. Samples of tape will
be reviewed to ensure transcription accuracy. Notes taken during the
focus groups were used to cross check accuracy. The information gathered
from the focus groups will be safeguarded against unauthorized
disclosures to the fullest extent legally possible in accordance with
applicable statutes.

Analysis of both interviews and focus groups was completed by CDC staff
from transcripts that had been de-identified by Battelle. Content
analysis, which allows researchers to make inferences from qualitative
data, was used to analyze responses to stakeholder interview question.
With this technique, a large amount of qualitative information could be
reduced to a series of variables that can be examined for relationships.

Data were coded and transcribed into Atlas-ti software for the content
analysis. The data coded by CDC were not provided to Battelle for
inclusion in this report. However, we have incorporated findings from
our own documentation of interviews.

# 3.0 Findings {#findings .unnumbered}

This section presents findings from the key stakeholder interviews. In
addition, we describe tendencies in responses from providers and
patients based on the data that we have available to us.

## 3.1 Political Will {#political-will .unnumbered}

The evaluation of political will in support of the Pilot Project was
conducted by Battelle. Evaluation questions on political will included:

-   Has the Pilot Project been effective from your perspective? Do you
    think it should continue?

-   What are the political and human factors needed to design and
    implement a project that requires the collaboration of many partners
    with different point of views and experiences?

-   What are the barriers and challenges to implementation of the Pilot
    Project specifically and to Binational projects more generally?

The key stakeholders with whom we spoke were committed to the project
and wanted to see it continue, although many had questions about how
this would happen. The approach of the two countries to health services
is quite different.

"the project is an ambitious project, but it has been successful. In the
border area, there is one region and two sovereignties. In Mexico,
public health is public and in the US it's commercial. Mexican
representatives from the consulate intervene to make sure co-nationals
get health care in the US. Health promotion and education are based on
the same promotion strategy. The problem in Mexico is in the follow-up
and in the US it is in \[treatment\].

\[Even though they anticipated problems\], there were operational goals
in the TB Pilot Project which were to get patients cured; work with the
Border Health Commission; and get strategic alliances. The Health
Secretary and General Secretary are committed to the project. People are
more worried about the operations of the project than the project's
goals.

From a public health perspective, policy makers in both countries were
interested in extending the Pilot Project beyond the border area, citing
limited benefits for the population that remains in the border area.
They indicated that a referral system was already in place for these
patients before the Binational Card program was established and they saw
little need for the Card program for these patients.

The border cities are not the source of immigrants. These cities are
found down in the south and central part of the country. We did data
analysis following the migratory routes from the Pacific Ocean and the
gulf in order to come up with correlations of the increase rate in
periods of 10 years -- we wanted to see if the data flow was having an
impact on the increase rate of cases in the migratory routes and of
course there was a correlation. There would be two important
settlements; Tamaulipas and Baja California. So, we realized that we did
not need to do this on the border but down under which is where could
have an impact. The truth is that there is not much "movimiento" at this
pilot site going to the US.

However, they felt that the card might be beneficial for patients who
move beyond the border. One public health official stated,

The other success was that we found patients that would travel from
Mexico to Chicago. People from Chicago wanted to participate. We found
patients that came from the US to other places like Michoacán... they
would ask when they could be part of the project so that they could get
materials and be able to send them over there. That was important. They
are participating in the project to report what happened with the
patient for referral or information but they are not giving out cards.

Some Mexican officials felt that the Pilot Project would be more useful
in the lower states of Mexico since these states have a higher number of
TB cases.

There was abundant evidence from key stakeholders that the effective
collaboration between health officials in the US and Mexico is a very
important outcome of the project for them.

*"The project is a bi-national collaboration and is a success. The
objective is to identify patients and get them cured."*

*The Pilot Project is a model for collaboration. Project staff in Texas
and California are more open-minded than previously thought and they are
mostly [Latinos]{.underline}. There is excellent communication between
the two sides. There is a political significance to the project. It's a
chance of telling the world US-Mexico collaboration can happen.*

*The project is moving and is geared towards improving follow up of
migrant patients receiving TB treatment considering that the background
of US-Mexico relations is not easy. The program is a success and it
shows the rest of the world that collaboration can exist and work
successfully between two countries.*

. . .Personally I think it's a success because it was a Binational
collaboration. That was very important. I don't know if the other
programs, like diabetes, have had that opportunity, but the experience
and the richness in having joint bi-national work teams has been
important.

do think is a success in a lot of intangible ways. I think that there
has been a lot of collaboration and good will that's been built to make
the project happen and as a result of the project, but I think in term
of actual numbers I don't think we're quite there to say that without
this project somehow all these patients would die. I don't think that's
really true. I think it's made its biggest impact in the intangible
sharing of data and collaboration and people knowing what's going on and
raising awareness.

Key stakeholders felt that another positive impact of the project has
been that both countries have gained a better understanding of migration
patterns within their own countries and between the two countries. One
health official noted,

We learned that TB was more specific in certain places and its
epidemiological profile is different. The profile of this project has
changed because it could be used politically, epidemiologically, in a
humanitarian context, internationally and this gives us experience to
see how we are going to use with the South. We want to stop the trend in
our South because we think that TB comes from the South to North. We
also think it come through from the Pacific and the border -- we did not
have this perspective before.

The system not only tells us that the patient has gone to the US, but
that he/she is moving to other places within a country. This is what the
card tells us. So, the card has given an added value -- knowing the
internal migrations which we did not have before.

Like all migration, a few people come and settle and others come to be
with them. Moreover, immigrants are not accustomed to letting people
know about themselves. Relatives remaining in Mexico in most cases, know
little about where there relatives go or what they do after they cross
the US-Mexico border. Moreover, not all TB cases that traverse the
border are discovered by health authorities. One informant described
Ciudad Juarez as a "ciudad de paso" (a city of passage). Many people
migrate from the interior, stay for two to six weeks, then cross the
border without ever seeking medical services. The Pilot Project has
helped here as well:

The impact now is that there is a lot of collaboration and there is
little bit more organization with TB in the border. If we could expand
it we could make a huge impact. We'd follow people. We would be able to
know what happen to them. It has huge possibilities.

IPolicy makers argue for mutual intelligence and exchange as a necessary
condition for any Binational project:

There needs to be an understanding of the two systems and the approach
to the Pilot Project must be based on consensus. There needs to be the
realization that a program has to be applied differently to different
regions in the countries because, in both countries, no two states'
health programs are the same.

The problems to be addressed and their causes vary from region to
region. An understanding of the capacity, public health infrastructure
and population is needed to implement a program -- a regional
perspective.

The experience of stakeholders in the Pilot Project led some of them to
ask for patience in working through the early stages of development of
Binational cooperation until the project has an opportunity to achieve
results.

I still believe in the project. It is not such a big thing as I thought
in the beginning. I have learned that frontiers are political -- not
from the people.

Many of the stakeholders with whom we spoke raised the issue of cost
early in our discussions. Costs are of several types: burden on staff,
direct costs of the program and indirect costs of identifying and
treating TB patients. The cost issue was a concern for many stakeholders
in considering the long-term sustainability of the Pilot Project. Policy
makers in Mexico said that there was simply unlikely to be additional
money for this project given other priorities. Even in the United States
that was some uncertainty about the economic viability of finding and
identifying new cases of tuberculosis without adequate funding to expand
treatment services.

## Role Of The Binational Projects In The Border Area

Evaluation questions were:

-   How do Binational projects contribute to the referral system and the
    Pilot Project?

-   Do they render the Pilot Project redundant between sister cities?

The key stakeholders overall felt that the Pilot Project made an
important contribution to the continuity of care for patients along the
border. Those on the Mexican side were emphatic about the positive role
of the project in TB control and would like to see it expanded to other
parts of Mexico in order to facilitate referrals within the country.
Others felt the project was worthwhile, but that it was too early to say
if it has significantly impacted treatment outcomes in the border.
Public health officials and health care workers said that the number of
TB cases is too small and treatment regimens are too long to determine
the impact of the project in terms of treatment completion and outcomes.
However, they felt that the project has made other impacts that will
improve TB control in the border, such as improved communication and a
better understanding of migration patterns.

One very important benefit of the Pilot Project in terms of TB control
in the border was that it asked no questions of patients about their
immigration status:

It is only important to establish that immigrants who are infected with
TB cross the border despite any efforts to prevent this. Regardless of
their legal status, they carry the disease with them. The Pilot Project
gives public health officials a chance to bring infected TB patients to
treatment regardless of their immigration status.

Authorities on both sides of the border viewed the Pilot Project as an
institutionalized program and not as a Pilot Project. Many of them see
the impact of the project and want to see it grow. An especially
important benefit was closer and better involvement of health care
workers and the population. One interviewee felt that it was not yet
clear whether providers are currently seeing more patients than they did
prior to the project.

The TB Pilot Project is considered very important because of the
alliances it created in the border area even though other Binational
programs preceded it:

*As opposed to other programs . . ., the Binational Pilot Project has
had other positive outcomes besides the card such as the good
relationship and support that exist now. Getting people who are
enthusiastic contributed to the success. There are good relationships
and collaboration with people in California and Texas, and this is
important for the project.*

*"It's not only about the card, but also about technical support,
project reviews, support, etc... These are all areas of work
opportunity, in terms of getting collaboration and support."*

*There always has been collaboration in the Binational project, but
these are brought about better by personal relationships than by
official agreements.*

*"The project has been demanding in terms of the work load, but the work
has been getting done somehow. Sometimes resources have been scarce;
however they have managed to find them through good relationships and
collaborations. "*

## Cross-border Communication

Evaluation questions were:

-   What was the communication between the National Program and CureTB?

-   How well does the communication work? How does it not work? How can
    it be improved?

-   What is the role played by the Binational Projects in facilitating
    communication in the border area?

The Pilot Project required ongoing dialogue across the border to
reconcile different perspectives about almost all aspects of the
project. For example, it took many iterations to design the card itself
because of problems in getting agreement between the US and Mexico. An
understanding of the conditions prevailing in the border area was
essential to the Pilot Project. One person felt that experience at work
meetings demonstrated that the knowledge of the border was not adequate
for the Pilot Project.

*". . . People who are from the capital or other cities don't have an
accurate notion of the border. The Border Health Commission and other
organizations that work on the border, do not work with \[the capitals
of the two countries\]. Advocacy must come from someone who knows about
TB in the border and the issues there.*

Two difficulties with data flow were mentioned in the stakeholder
interviews. One of these was early uncertainty about the division of
data management responsibility between CureTB and TBNet. The Pilot
Project was similar to TBNet, a project of the Migrant Clinicians
Network in the El Paso-Ciudad Juarez area. although TBNet did not cover
the same population as the Pilot Project. At first there was confusion
when the Pilot Project was implemented because CureTB and TBNet both
were being used as referral programs and people did not know where to
send patients. The relationship improved after a division of labor was
negotiated whereby Cure TB tracked patients crossing the border and
TBNet traced patients migrating from the border into the interior of the
United States. Also the Pilot Project is sponsored bi-nationally and
allows information sharing outside of El Paso/Juarez while TBNet
functioned locally.

Although data flow across the border was not perceived as a problem by
key stakeholders, the slow pace of data flow within Mexico was a problem
for the Pilot Project that was never satisfactorily resolved. Case
reporting and data management are much more centralized in Mexico than
that in the US. TB cases are reported to the National Epidemiological
Program along a chain of responsible agencies from the clinic to the
jurisdiction to the State to the National Tuberculosis Prevention
Program. NTP enters the data into a database, summarizes them and
disseminates them down through the health system. An agreement was
signed by the states which commit them to use a computer program to
register TB cases. This means that there are delays in case reports as
they moved from the Pilot Project through the levels of the health
system up to Mexico City, then back down to the local level where the TB
case was managed. This made timely intervention in cases, as well as
evaluation of the Pilot Project difficult.

The NTP data system that is used to manage TB data is an EpiInfo system.
It works well, but training is needed at the local level. Also there is
a lack of resources at the health centers and it is hard to provide
computers to all of them. Most health units in Mexico do not even have a
phone, much less a fax machine. Some have one person responsible for
tracking everyone. Others don't even have this. Some lack transport to
search for people. There has not been much progress in training,
laboratories and case management. There is a greater need for testing
(Chest x-rays) and treating patients.

Additionally, in Mexico, jurisdictional administrators working at the
level above local providers are in charge of getting information and
making decisions. In the Pilot Project they have been using paper trails
because it was a Pilot Project and they had no resources. However,
adequate computers in each site will be needed to improve the work of
the health centers should the project be fully implemented..

## Coordination With Immigration Authorities/Jails/Prisons

Evaluation questions are

-   What are examples of effective collaboration?

-   What barriers, challenges or other factors facilitate or impede
    collaboration?

Developing cooperation with immigration authorities around screening,
referral and treatment of TB patients in detention facilities was an
important achievement of the Pilot Project. The Pilot Project was
formally integrated into the detainee screening process and into the job
responsibilities of the health care staff in the Immigration Control and
Enforcement (ICE) facilities. It appears that the process worked
effectively, due to both formal integration of the Pilot Project
procedures into operations and the concrete support provided by Pilot
Project staff. ICE staff expressed commitment to the project from the
highest level to those responsible for the details of the program. The
project increased the number of ICE detainees for whom data are
currently being collected.

I think where it's made any kind of epidemiological impact, it's
probably in the ICE detention center where it has been solidified as a
referral mechanism and in that sense we have probably have made a
difference. ICE thinks we have, in terms of being able to follow up
patients. Before they couldn't and they can \[now\]. In that sense I
think it's been successful, and in the collaboration ways, but I think
we're still far out from being able to say that it's already successful.
In real epidemiological \[sense\] I think it's not quite there.

Negotiations with the jails and detention centers have resulted in
agreements with these institutions to notify the Department of Health
prior to deporting a patient, although occasionally the individual is
deported after having been identified with TB within 24 hours and
without notification. This situation seems to be improving.

It was also challenging to obtain patient information from the detention
centers in a timely manner. Detention centers say that they do not have
clinical staff to follow through. The lines of responsibility are not
always clear; the Department of Health is dependent on the detention
centers to provide information, but they are not sure how much they
should press the detention centers for this information because they
have no legal authority to do so. Overall the communication is
improving. Public health officials in El Paso note that it is difficult
to track cases traveling to the interior of Mexico because JUNTOS is not
in place to assist with coordination.

## Perspective And Opinion Of The Health Care Workers

Evaluation questions include:

-   Is the Card useful to providers?

-   Is it worth including in routine program activities?

-   Is it difficult to integrate into routine program activities?

-   How can the process be improved?

While the tracking and control of TB in the border improved over the
course of the Pilot Project, it was due not only to use of the
Binational Card, but to the educational materials that went with the
card and created patient and provider awareness of TB and a "conscience
about referral of TB patients". The Pilot project also provided
technical assistance on prevention, management and control of TB.
Without the card and these other assets, TB control would still occur in
the border, but the Pilot Project improved technical quality of the
program and improved the knowledge underlying TB programs. The card
created a system of communication among local health departments across
the state and the border.

The burden of the Pilot Project on the staff of participating
organizations was mentioned the most often. Staff were required to add
duties related to the Pilot Project to their existing tasks. And the
Pilot Project created more work in routine activities:

For TB where control equals treatment, any improvement to the detection
of cases creates an increase in the number of cases to be treated. Funds
to treat patients do not come from CDC, but from the state. It will be a
burden because there are more patients appearing at the public health
department for treatment, especially if they are complicated cases
requiring second line medications.

At first some staff argued that the project was too much more work with
no more pay and no more hours available. Agency heads said several times
that staff kept it up because they believed in the project and because
it was a Pilot Project that would end. Still there were many calls for
additional staff work on the Pilot Project. This is a special issue for
people who work for non-profits and have to account for their time. Some
US interviewees talked about "unfunded mandates"

## Patients' Perspective And Opinion

Evaluation questions are:

-   Is the Card useful to patients?

-   Is the system trustworthy and trusted?

-   How could the system be improved?

The patients in the focus groups were chosen because they had used the
card. Generally they also liked it because it allowed them obtain and
continue treatment while moving between healthcare clinics on both sides
of the border. In a typical case, one patient reported that he was
diagnosed with TB in Tijuana and received the card, which he then used
when he went to San Diego. He said that his records were faxed from
Tijuana to San Diego where he continued treatment. He thinks the card is
good to get information quickly from one side to the other and that it
facilitates quicker treatment and treatment completion.

## Patients' Experience At Destination

Specific evaluation questions are:

-   What are differences between pilot sites and non-pilot sites in how
    referrals are managed?

-   What kind of a welcome did patients receive?

-   Is the Card sufficient for patients to access care?

Although Chicago and Michoacán were not part of the pilot project, a
patient traveling between these two cities reported that he was able to
use the card to continue treatment when he traveled even between
destinations that were not yet Pilot Project sites. The following
anecdote was provided by a provider about a patient:

. . . having the card has been good because he was able to receive his
medications. He traveled from Chicago to Michoacán and continued his
treatment. When he first received the card, he thought it was not going
to work. They told him to show it at any medical center so that he could
receive his medication, but he did not think that that was going to be
case. In Michoacan, he went to a medical center where they did not
accept the card -- they told him that he did not belong to that medical
center. Then, he went to another health center and they gave him the
medications. They asked if he had been referred by a doctor in the US.
He said yes. The providers in the US and in Mexico communicated and
exchanged information about his case. They gave him more medications
than he needed.

As expected, patients lost to follow up were extremely difficult to
contact for a variety of reasons. Phone numbers were no longer in
service or did not exist, patients had moved, or patients did not feel
well enough at that time to complete an interview. Of the four patients
we did reach, two reported that they had finished their TB treatment at
sites that did not participate in the Binational project (hospital in
Los Angeles and clinic in Michoacán). The daughter of another patient
reported that a nurse came to the house daily to administer the pills to
her mother, but now treatment is complete. The daughter went on to
express her dissatisfaction with the care her mother received and
stated,

She \[her mother\] would not react well to the medications which would
cause her to throw up and feel sick every time. \[I\] told the nurses,
but they continued to administer the treatment. After seeing the
reaction her mother had to the treatment medication, does not plan to
take her mother to the doctor unless she feels sick.

While these patients were lost to follow up by Cure TB, they did in fact
complete treatment. Of the patients we contacted on the lost to
follow-up list, only one had not completed treatment. This patient
reported he has restarted treatment, but work commitments have prevented
him from staying on schedule with the treatment regimen. The patient
said that his job has made it difficult for him to adhere to the
medication regimen.

# 4.0 Recommendations from Key Stakeholders {#recommendations-from-key-stakeholders .unnumbered}

In conclusion, the Pilot Project seems to have gone well in spite of a
number of start up difficulties and a few problems that were never
resolved, and perhaps cannot be resolved. The slow data flow in Mexico
reduced the usefulness of the data to health providers who were
operating TB control programs in the border. The labor burden imposed on
public health staff was acceptable in a Pilot Project but would need to
be addressed in a more systematic way for the project to be replicated
elsewhere and sustained. However, by and large the project was a model
for effective and productive collaboration of a large number of
organizations across the US-Mexico border, extending even to the federal
level in both countries. As our informants told us, the Pilot Project
demonstrated what can be done. This is in no small part due to the
unceasing effort on the part of CDC and the NTP in Mexico to promote
ongoing meetings and discussions of the Pilot Project, its successes and
its struggles, broadly among a large number of organizations. The
commitment of the partners to this project was notable, extending even
to their active participation in the evaluation.

Reconciling the needs of two very different health systems was a
challenge for the Pilot Project. There is much common ground between the
US and Mexican systems. Like the US, Mexico has a national public health
structure (the Secretario de Salud) and state health departments. Many
Mexican public health officials have studied for some period of time at
CDC or in US schools of public health. However, there are important
differences between US and Mexican health systems. In the United States,
the prevention and control of infectious diseases, including reporting,
is a state responsibility with CDC providing support, training and
technical assistance. In Mexico, in spite of a decentralization of
public health functions over the past decade, most decisions about
public health are still made at the federal level. Mexico has an
additional layer of public health organization, the regional health
departments in addition to the federal, state and local levels. Each of
these levels has its own rights and responsibilities, which cannot be
directly inferred from the organization of public health in the United
States. Differences in the organization of public health are exacerbated
by a history of perceived power differentials between the US authorities
and those in Mexico, a legacy of the history of the border.[^5] These
political considerations made both the Pilot Project and its evaluation
heavily dependent on day-to-day collaboration of public and private
health staff at several levels of government and in the public sector as
well as among private providers. This was both a challenge and a great
strength of this project.

The following recommendations were made by more than one key stakeholder
and are included here for use in the event of a replication of the Pilot
Project. We have presented these without elaboration because they seem
to us to be exhaustive.

## Policy Recommendations from Key Stakeholders

*Expand the Pilot Project*

There was wide agreement among key stakeholders that CDC should continue
and expand the Pilot Project, both to other areas and to other agencies,
other institutions and other diseases. A more extensive network should
be created across the border and across the participating states. The
project should be expanded not only to all the border cities, but to
lower states in Mexico from which many patients with TB in the border
originate. Within Mexico, the project should be expanded institutionally
to include TB patients in other parts of the Mexican health system.
Finally it was suggested that the concept of the card and the experience
of the Pilot Project could serve as a model for other diseases such as
HIV.

*Publicize the Purpose and Achievements of the Pilot Project*

There was some uncertainty among health officials, providers and the
general public about the operation of the Pilot Project. There needs to
be better dissemination of information about TB itself, what the Pilot
Project is doing and the benefits of it to them. Awareness of the
project needs to be raised at the Federal level in both countries as
well as at the local level. One person suggested that mass media
marketing may be too costly, but local marketing -- in newspapers, local
radio, and signage -- is more reasonable and reaches many people.

*Coordinate the Card with All Involved Agencies*

Coordination of the many agencies and organizations that participated in
the Pilot Project in the two countries came up several times. Several
interviewees were concerned about the coordination of multiple
bi-lateral projects operating in the border area at different levels of
government. Those who operate the project in the future might identify
opportunities for collaboration with organizations that have experience
working with legal issues around immigration status. All non-government
organizations involved in the project should coordinate to help protect
the confidentiality of patients. Operationally, it was recommended that
cooperating agencies have designated contact coordinators and that they
be referred to Pilot Project staff for technical assistance.

*Involve Staff at the Operational Level*

There was some concern that staff who are directly involved in
implementing the program (providers, case workers, outreach staff) were
not involved in early project activities, including training. All staff
working at the level of program operations should be trained in
procedures involved in issuing and tracking Card patients and provided
with technical assistance thereafter. To facilitate this, Pilot Project
administrators should work with localities and jurisdictions to
understand their capacity and their needs relative to the operation of
the Pilot Project. They should also develop methods to get regular
feedback from staff at the operational level. Several interviewees also
urged that CDC plan for ongoing technical assistance and continuing
training of public health staff who work with the project.

*Change Criteria for Card Eligibility*

The Pilot Project procedures specify that the care should be given only
to TB patients who plan to migrate. However, some health officials do
not feel that this is a reliable criterion for eligibility. JUNTOS and
the participating Mexican jurisdictions give the card to all TB patients
on the assumption that all are potential migrants. Also many Mexicans do
not receive the card because they are covered by non-participating
social security programs in Mexico. Those who receive health care either
under the Mexican Social Security Program or who have coverage from
ISSTE (workers insurance) do not get cards because they do not appear at
public clinics. An effort should be made to reach these TB patients with
the card if the card program is to be as effective as it can be.

## Recommendations for Program Improvement from Key Stakeholders 

*Specific Program Improvements*

Interviewees had many recommendations for specific steps to be taken
that would improve the operation of the Pilot Project. The card should
be given to all patients rather than only to those who state an
intention to migrate. One interviewee felt that the design of the card
should be evaluated and changed if necessary. Patient education should
be emphasized. One person called for a more efficient referral system of
TB cases. The Card should be used in a confidential manner. It should be
used only to administer treatment. This is important because confidence
in confidentiality makes the patient feel protected. Patients should be
interviewed to get the client perspective on confidentiality. CDC and
its partners should capture the new challenges and strategies that come
out of the evaluation and geared all changes to benefit immigrants.

*Data and Systems Support*

There was some discussion of information gathering. A better data
exchange system is needed. For evaluation purposes, the use of the Card
should eventually be reflected in lower TB morbidity and this should be
reflected in the data. This can only happen if providers report cases of
TB at the local level and the information moves through the system.
Perhaps the Card itself could remind providers to do so. In this way the
card can be used both as a statistic and treatment tool.

*Improved Communications*

Good collaboration and communication is essential in a project of this
organizational complexity. One informant told us that Pilot Project is
successful because of the good communication that exists now while
another complained of a lack of communication. Interviewees called for
better inter-jurisdictional communication between jurisdictions on an
ongoing basis. Perspectives of the health care staff need to be known
and considered. Different perspectives from different participants, for
example CureTB and TBNet, need to be taken into account and reconciled.

*Utilization of Evaluation*

Interviewees considered ways in which evaluation can be used to improve
the program. They were especially interested in ways to assess
infrastructure and understand capacity, a recommendation that will be
especially important if the Pilot Project is expanded to other
jurisdictions.

## Recommendations from Key Stakeholders for Resources Needed to Sustain the Program

*Funding*

Eight of twelve stakeholder interviewees volunteered that funding of the
Pilot Project is inadequate to sustain the program on an ongoing basis.
One person said, "The project should be funded adequately to be
implemented properly. This implies funding for treatment,
infrastructure, education and staff." Other program areas mentioned as
needing increased funding were improved communications, additional
support of fieldwork and bringing in other states or sites.

*Staff*

Two interviewees called for a full time coordinator in their
organization to work with the TB Border Health Commission, the Mexican
Secretariat of Health and CDC on the Pilot Project.

*Others*

Other resources mentioned included funds for additional treatment costs
incurred as more patients are identified and to support expansion of the
scope of activities of the TB program because of the Pilot Project.
Funding for additional medications to be distributed by the Health
Department to Card patients was mentioned. Finally, two people called
for more educational materials such as brochures, manuals and posters.

[^1]: MMWR, Recommendations for Prevention and Control of Tuberculosis
    Among Foreign-Born Persons. . September 18, 1998, 48(RR16).

    Tuberculosis Screening among foreign-born persons applying for
    permanent US residence, American Journal of Public Health 92(5):
    826-829. May 2002.

[^2]: MMWR, Targeted Tuberculin Testing and Treatment of Latent
    Tuberculosis Infection, June 9, 2000, 49 (RR-6).

[^3]: Computed from data presented at the November 1997 Meeting of Ten
    Against TB, an international partnership of border states that has
    worked together to improve TB prevention and control in the border
    area.

[^4]: MMWR, Population-based survey for drug-resistance of tuberculosis
    -- Mexico 1997, 47(18): 372-5, May 151998.

[^5]: Heyman, J McC, "The Mexico-United States border in anthropology: A
    critique and reformulation", Journal of Political Ecology 1:43-66.
    1994.