TB training in Kenya: building capacity for care and prevention.

BACKGROUND: Devolution of healthcare services in Kenya resulted in a large number of newly recruited tuberculosis (TB) coordinators. We describe a unique collaboration between a national tuberculosis program (NTP), a local, and an international non-governmental organization to build human resource capacity in TB care and prevention. METHODS: From 2016 to 2021, the Kenya Division of National Tuberculosis, Leprosy and Lung Disease Program, Centre for Health Solutions-Kenya, and the International Union Against Tuberculosis and Lung Disease developed and conducted a series of 7-day training courses. A key focus of training was the introduction of TBData4Action, an approach involving the local use of routinely available data to strengthen decision-making and support supervision. RESULTS: Implementation outcomes included training 331 (96%) coordinators out of 344, representing all 47 counties, 37 national officers and 21 other stakeholders using the country-tailored curriculum, including hands-on group work by county teams and field practicals. Thirty-five national facilitators were identified and mentored as local faculty. Training costs were reduced by 75% compared with international alternatives. CONCLUSION: The collaboration resulted in the training of the majority of the coordinators in a standardized approach to TB care. A sustainable approach to capacity building in local data use was found feasible; the model could be adapted by other NTPs.

CONTEXTE: La décentralisation des services de santé au Kenya a conduit au recrutement d'un grand nombre de nouveaux coordinateurs TB. Nous décrivons une collaboration unique entre un programme national de lutte contre la TB (NTP), une organisation non gouvernementale locale et une organisation non gouvernementale internationale visant à renforcer les capacités humaines en matière de prévention et de soins de la TB. MÉTHODES: De 2016 à 2021, la division kényane du programme national de lutte contre la tuberculose, la lèpre et les maladies respiratoires, le Centre for Health Solutions-Kenya et l'Union internationale contre la tuberculose et les maladies respiratoires ont développé et dispensé une série de formations en 7 jours. La formation mettait l'accent sur l'introduction de l'approche TBData4Action, qui promeut une utilisation locale des données disponibles en routine afin de renforcer la prise de décision et d'épauler les activités de supervision. RÉSULTATS: Les résultats de la mise en place de cette formation comprenaient la formation de 331 (96%) coordinateurs sur 344, représentant l'ensemble des 47 pays, 37 administrateurs nationaux et 21 autres acteurs formés à l'aide du programme adapté aux besoins du pays concerné (dont travail de groupe pratique par les équipes nationales et travaux pratiques sur le terrain). Trente-cinq facilitateurs nationaux ont été identifiés et formés comme enseignants locaux. Les coûts de la formation ont été réduits de 75% par rapport aux alternatives internationales. CONCLUSION: La collaboration a permis de former la majorité des coordinateurs à l'aide d'une approche standardisée de soins de la TB. Une approche durable de renforcement des capacités en matière d'utilisation des données locales s'est avérée réalisable. Ce modèle peut être adapté à d'autres NTP.

Should we consider a 'fourth 90' for tuberculosis?

The international community has committed to end the tuberculosis (TB) epidemic by 2030. To facilitate the meeting of the global incidence and mortality indicators set by the World Health Organization's End TB Strategy, the Stop TB Partnership launched the three 90-(90)-90 diagnostic and treatment targets in 2014. In this paper, we argue that a 'fourth 90'-Ensuring that 90% of all people successfully completing treatment for TB can have a good health-related quality of life'-should be considered. Many individuals who successfully complete anti-TB treatment are burdened with lifelong comorbidities-human immunodeficiency virus (HIV) and diabetes mellitus, obstructive and restrictive lung disease, involving lung destruction, cavitation, fibrosis and bronchiectasis, that either pre-existed or developed as a result of TB (e.g., chronic pulmonary aspergillosis), permanent disabilities such as hearing loss resulting from second-line anti-TB drugs, and mental health disorders. These need to be identified during TB treatment and appropriate care and support provided after anti-TB treatment is successfully completed. A 'fourth 90' has also been proposed for the UNAIDS 90-90-90 targets similar in scope to what is being suggested here for TB. Adoption by both HIV and TB control programmes would highlight the current focus on integrated person- and family-centred services.

Feasibility and yield of screening for diabetes mellitus among tuberculosis patients in Harare, Zimbabwe.

SETTING: A resource-limited urban setting in Zimbabwe with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV). OBJECTIVES: To determine the feasibility and yield of diabetes mellitus (DM) screening among TB patients in primary health care facilities. DESIGN: A descriptive study. RESULTS: Of the 1617 TB patients registered at 10 pilot facilities, close to two thirds (60%) were male and 798 (49%) were bacteriologically confirmed. The median age was 37 years; two thirds (67%) were co-infected with HIV. A total of 1305 (89%) were screened for DM, and 111 (8.5%, 95% CI 7.0-10.2) were newly diagnosed with DM. Low TB notifying sites were more likely than high TB notifying sites to screen patients using random blood glucose (RBG) (83% vs. 79%; P < 0.04). Screening increased gradually per quarter over the study period. There were, however, notable losses along the screening cascade, the reasons for which will need to be explored in future studies. CONCLUSION: The study findings indicate the feasibility of DM screening among TB patients, with considerable yield of persons newly diagnosed with DM. Scaling up of this intervention will need to address the observed losses along the screening cascade.

Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors.

A global survey of National Tuberculosis Program (NTP) directors. To assess the perceived mental health needs of persons with tuberculosis (TB), current practices, and receptivity to integrating evidence-based mental and substance use treatment into national TB guidelines. Semi-structured survey of NTP directors from 26 countries of all income levels using a standardized questionnaire. Of the 26 countries, 21 were classified as high incidence and/or burden countries for TB, TB and human immunodeficiency virus coinfection, and/or drug-resistant TB. Two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. If effective and low-cost integrated care models were available, 17 NTP directors felt that it was highly likely, and five somewhat likely, that their NTPs would integrate mental health treatment into national TB guidelines and services. The main perceived barriers to service integration were limited capacity, not recognizing mental health as a problem, insufficient resources, and TB-related social stigma. NTPs currently do not address mental disorders as part of routine practice. Nevertheless, receptivity is high, which creates a ripe opportunity to integrate the management of TB and mental disorders into the policies and guidelines of NTPs worldwide. .

Local staff making sense of their tuberculosis data: key to quality care and ending tuberculosis.

The End TB Strategy's ambitious targets require universal health coverage, new tools and better data to monitor progress. To assess the feasibility of a novel approach, whereby facility and district staff analyse and use their tuberculosis (TB) data to strengthen the quality of patient care and data. This approach was piloted in Zimbabwe, and performance before and during the study were compared. Key indicators were defined for presumptive TB, TB disease, drug-resistant TB, TB and human immunodeficiency virus (HIV) co-infection, treatment outcomes, directly observed treatment and drug management. Staff validated, tabulated and analysed data quarterly to identify challenges and agree on action points at 'data-driven' supervision and performance review meetings. In the district that fully implemented the new approach, there was a significant increase in the identification of presumptive TB (63% vs. 30% in the rest of the province; P < 0.00001) and new smear-positive TB cases (87% vs. a decrease in the rest of the province; P < 0.0001), and a decline in the rate of pulmonary TB cases without diagnostic smear results (77% vs. 20% in the rest of the province; P = 0.037). The present study suggests that this approach led to an improvement in the quality of patient care and data, stimulated local staff to set priorities and increased 'ownership'. This approach can significantly help attain national TB goals and strengthen health systems. .

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

How can integrated care and research assist in achieving the SDG targets for diabetes, tuberculosis and HIV/AIDS?

Integrating the management and care of communicable diseases, such as tuberculosis (TB) and human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS), and non-communicable diseases, particularly diabetes mellitus (DM), may help to achieve the ambitious health-related targets of the Sustainable Development Goals (SDG 3.3 and 3.4) by 2030. There are five important reasons to integrate. First, we need to integrate to prevent disease. In sub-Saharan Africa, in particular, HIV infection is the main driver of the TB epidemic, and antiretroviral therapy combined with isoniazid preventive therapy (IPT) can reduce TB case notification rates. In Asia, DM is another important driver of the TB epidemic, and preventing or controlling DM can reduce the risk of TB. Second, we need to integrate to diagnose cases. Between a third to a half of those living with HIV, TB or DM do not know they have the disease, and bi-directional screening, whereby TB patients are screened for HIV and DM or people living with HIV and DM are screened for TB, can help to identify these 'missing cases'. Third, we need to integrate to better treat and manage patients who have a combination of two or more of these diseases, so that treatment success and retention on treatment can be optimised. Fourth, we should integrate to ensure better infection control practices for both TB and HIV infection in health facilities and congregate settings, such as prisons. Finally, we should integrate and learn how to monitor, record and report, particularly in relation to the cascade of events implicit in the HIV/AIDS and TB 90-90-90 targets.

Risk factors for unfavourable treatment outcome among new smear-positive pulmonary tuberculosis cases in China.

Setting: Three projects of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB. Objectives: To assess unfavourable treatment outcomes (UTOs), including failure, died, loss to follow-up (LTFU), transferred out and unknown outcome, and to identify risk factors associated with UTOs. Design: This was a cross-sectional study using routine programme data. Results: Of 30 277 new smear-positive tuberculosis (TB) patients, 4261 (14.1%) had UTOs: 2048 (6.8%) LTFU, 1418 (4.7%) transferred out, 390 (1.3%) died, 340 (1.1%) failed and 65 (0.2%) had an unknown outcome. Risk factors for LTFU (including LTFU, transfer out and unknown outcome) were residing in Anhui, age > 55 years, service delay > 10 days, patient delay < 30 days, directly observed treatment (DOT) provided by a family member or others and unknown DOT provider. The outcome of 'died' was associated with residing in Shaanxi, age > 55 years, male sex, patient delay > 30 days and unknown DOT provider. 'Failed' was associated with having unlimited access to health services, patient delay of >30 days and unknown DOT provider. Conclusion: This study highlights the predominance of lost patients among UTOs. Patients with family members or other non-medical DOT providers or unknown DOT providers had a high risk of a UTO. There is an urgent need to address these service-related factors.

Contexte : Trois projets du Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB (FIDELIS).Objectifs : Evaluer les résultats défavorables du traitement (UTO) incluant l'échec, le décès, les pertes de vue, les transferts et les résultats inconnus, et identifier les facteurs de risque associés aux UTO.Schéma : Une étude transversale basée sur des données de routine du programme.Résultats : De 30 277 nouveaux patients TB à frottis positif, 4261 (14,1%) ont eu un UTO : perdus de vue (2048 ; 6,8%), transférés (1418 ; 4,7%), décédés (390 ; 1,3%), en échec (340 ; 1,1%) ou inconnus (65 ; 0,2%). Les facteurs de risque de perte d'un patient (incluant les patients perdus de vue, transférés et inconnus) ont été le fait de vivre à Anhui, l'âge > 55 ans, un délai du service > 10 jours, un retard du patient < 30 jours et le traitement directement observé (DOT) fourni par un membre de la famille ou d'autres personnes ou un prestataire de DOT inconnu. Le résultat « décès ¼ a été associé avec le fait de vivre à Shaanxi, l'âge > 55 ans, le sexe masculin, un retard du patient > 30 jours et un prestataire de DOT inconnu. Un « échec ¼ a été associé avec un accès non limité aux services de santé, un retard du patient > 30 jours et un prestataire de DOT inconnu.Conclusion : L'étude a mis en lumière la prédominance de pertes de vue parmi les UTO. Les patients ayant comme prestataire de DOT un membre de la famille ou un autre prestataire non médical ou inconnu ont eu un risque élevé d'UTO. Il y a un besoin urgent d'aborder ces facteurs liés au service.

Marco de referencia: Tres proyectos del Fondo de Estrategias Innovadoras de Ampliación de DOTS mediante Iniciativas Locales para Detener la Tuberculosis (FIDELIS).Objetivos: Evaluar los desenlaces terapéuticos desfavorables (UTO) que incluyen el fracaso terapéutico, la muerte, la pérdida durante el seguimiento, la transferencia a otro centro y el desenlace desconocido y definir los factores de riesgo que se asocian con estos resultados.Método: Un estudio transversal a partir de los datos corrientes del programa.Resultados: Se incluyeron en el estudio 30 277 casos nuevos de tuberculosis (TB) con baciloscopia positiva. De estos pacientes, 4261 tuvieron UTO (14,1%), a saber: perdidos durante el seguimiento (2048; 6,8%), transferidos a otro centro (1418; 4,7%), fallecidos (390; 1,3%), fracasos (340; 1,1%) o desenlaces desconocidos (65; 0,2%). En Anhui, los factores de riesgo de pérdida durante el seguimiento (incluidas las pérdidas, las transferencias a otro centro y los desenlaces desconocidos) fueron la edad > 55 años, un retraso dependiente del servicio > 10 días, un retraso dependiente del paciente < 30 días y el tratamiento bajo observación directa (DOT) suministrado por miembros de la familia u otras personas y un dispensador de DOT desconocido. En Shaanxi, el desenlace 'fallecido' se asoció con la edad > 55 años, el sexo masculino, un retraso dependiente del paciente > 30 días y un dispensador de DOT desconocido. El 'fracaso' se asoció con el hecho de no pertenecer a la categoría de acceso limitado a los servicios de salud, el retraso dependiente del paciente > 30 días y un dispensador de DOT desconocido.Conclusión: El estudio puso de manifiesto el predominio de la pérdida durante el seguimiento en los desenlaces desfavorables del tratamiento antituberculoso. Los pacientes que recibían el DOT por parte de un miembro de la familia o de otra persona diferente a un profesional de salud o cuyo dispensador de DOT se desconocía presentaron un alto riesgo de UTO. Es urgente abordar estos factores que dependen de los servicios de salud.

Are HIV-positive presumptive tuberculosis patients without tuberculosis getting the care they need in Zimbabwe?

SETTING: Emakhandeni Clinic provides decentralised and integrated tuberculosis (TB) and human immunodeficiency virus (HIV) care in Bulawayo, Zimbabwe. OBJECTIVES: To compare HIV care for presumptive TB patients with and without TB registered in 2013. DESIGN: Retrospective cohort study using routine programme data. RESULTS: Of 422 registered presumptive TB patients, 26% were already known to be HIV-positive. Among the remaining 315 patients, 255 (81%) were tested for HIV, of whom 190 (75%) tested HIV-positive. Of these, 26% were diagnosed with TB and 71% without TB (3% had no TB result recorded). For the 134 patients without TB, antiretroviral treatment (ART) eligibility data were recorded for 42 (31%); 95% of these were ART eligible. Initiation of cotrimoxazole preventive therapy (CPT) and ART was recorded for respectively 88% and 90% of HIV-positive patients with TB compared with respectively 40% and 38% of HIV-positive patients without TB (P < 0.001). CONCLUSION: Presumptive TB patients without TB had a high HIV positivity rate and, for those with available data, most were ART eligible. Unlike HIV-positive patients diagnosed with TB, CPT and ART uptake for these patients was poor. A 'test and treat' approach and better service linkages could be life-saving for these patients, especially in southern Africa, where there are high burdens of HIV and TB.

Contexte : Le centre de santé Emakhandeni, qui offre une prise en charge de la tuberculose (TB) et du virus de l'immunodéficience humaine (VIH) décentralisée et intégrée à Bulawayo, Zimbabwe.Objectifs : Comparer la prise en charge du VIH pour les patients présumés tuberculeux, avec et sans TB, enregistrés en 2013.Schéma : Etude rétrospective de cohorte basée sur les données de routine du programme.Résultats: Sur 422 patients présumés tuberculeux enregistrés, 26% étaient connus comme VIH positifs. Parmi les 315 patients restants, 255 (81%) ont eu un test VIH, dont 190 (75%) se sont avérés positifs. Parmi eux, 26% ont eu un diagnostic de TB et 71% n'ont pas été confirmés tuberculeux (les 3% restants n'ont eu aucun résultat de TB enregistré). Pour les 134 patients sans TB, les données d'éligibilité au traitement antirétroviral (ART) ont été notées chez 42 (31%) patients et 95% ont été éligibles à l'ART. La mise en œuvre du traitement préventif par cotrimoxazole (CPT) et l'ART a été notée pour respectivement 88% et 90% des patients VIH positifs avec TB, comparés à respectivement 40% et 38% des patients VIH positifs sans TB (P < 0,001).Conclusion : Les patients présumés TB mais non confirmés avaient un taux élevé de positivité au VIH et pour ceux dont les données étaient disponibles, la majorité était éligible à l'ART. Par contre, pour les patients VIH positifs sans une TB confirmée, le taux de mise en œuvre du traitement préventif par CPT et de l'ART a été médiocre. Une approche « tester et traiter ¼ et de meilleurs liens entre les services pourraient sauver la vie de ces patients, surtout en Afrique australe où les taux de VIH et de TB sont très élevés.

Marco de referencia: El consultorio Emakhandeni ofrece atención descentralizada e integrada de la tuberculosis (TB) y la infección por el virus de la inmunodeficiencia humana (VIH) en Bulawayo, Zimbabue.Objetivo: Comparar el servicio de atención de la infección por el VIH en los pacientes registrados con presunción clínica de TB cuyo diagnóstico se confirmó o se infirmó en el 2013.Método: Fue este un estudio retrospectivo de cohortes a partir de los datos corrientes del programa.Resultados: De los 422 pacientes registrados con presunción clínica de TB, el 26% contaba ya con una serología positiva frente al VIH. De los 315 pacientes restantes, en 255 se practicó la serología (81%) y 190 obtuvieron un resultado positivo (75%). De estos pacientes se confirmó el diagnóstico de TB en el 26% y se infirmó en el 71% (en el 3% no se registró ningún resultado sobre la TB). De los 134 pacientes sin TB, se consignaron datos sobre los criterios de inclusión en el tratamiento antirretrovírico (ART) en 42 casos (31%) y el 95% cumplía con estos criterios. En los pacientes seropositivos frente al VIH con TB se registró el comienzo del tratamiento preventivo con cotrimoxazol (CPT) en el 88% y del ART en el 90%, en comparación con el 40% y el 38%, respectivamente, en los pacientes seropositivos sin diagnóstico de TB (P < 0,001).Conclusión: Los pacientes con presunción clínica de TB en quienes se infirmó el diagnóstico presentaron una alta tasa de seropositividad frente al VIH y en los pacientes con datos registrados, la mayoría cumplía con los criterios de iniciación del ART. En estos pacientes la aceptación del CPT y el ART fue baja, a diferencia de los pacientes seropositivos con diagnóstico de TB. Una estrategia de 'prueba diagnóstica y tratamiento' y una mayor vinculación de los servicios podrían contribuir a salvar vidas en este grupo de pacientes, sobre todo en el sur de África, donde existen altas tasas de morbilidad por la infección por el VIH y la TB.

The Ethiopian initiative to build sustainable capacity for operational research: overview and lessons learned.

SETTING: Programme-based operational research is instrumental for the enhancement of tuberculosis (TB) control. In 2012, the Ethiopian Federal Ministry of Health launched an initiative for capacity building in operational research (OR). OBJECTIVE: To develop sustainable capacity for OR in Ethiopia in a multiyear initiative. DESIGN: The initiative was developed in collaboration with regional, national and international experts. Teams representing regions in Ethiopia conducted OR addressing national and regional priorities. To make use of local expertise and increase sustainability, a domestic mentor training programme was included. Existing capacity was enhanced through a competitive grant scheme providing TB researchers with financial and technical support. The Ethiopian Tuberculosis Research Advisory Committee was also supported in its functions. Regional ethics review bodies were strengthened or established where they did not exist. RESULTS: Fifty-two people were trained and conducted 13 OR projects, of which six have been published to date. In addition, eight protocols were supported through grants. Ethics review bodies were strengthened in all regions. CONCLUSION: The initiative trained participants from all regions and succeeded in the completion of all stages of the OR process. The success of the programme can be attributed to the team approach, 'learning while doing', integrated mentorship programme and strong national ownership.

Contexte : La recherche opérationnelle programmatique joue un rôle majeur dans la lutte contre la tuberculose (TB). En 2012, le ministère éthiopien de la santé a lancé une initiative de renforcement des capacités en recherche opérationnelle (OR).Objectif : Développer des capacités pérennes d'OR en Ethiopie dans le cadre d'une initiative s'étalant sur plusieurs années.Schéma : L'initiative a été élaborée en collaboration avec des experts régionaux, nationaux et internationaux. Des équipes représentant les régions d'Ethiopie ont réalisé une OR relative aux priorités nationales et régionales. Un programme de formation de mentors domestiques a été inclus afin d'exploiter l'expertise locale et d'accroitre la pérennité. La capacité existante a été renforcée grâce à un financement compétitif offrant aux chercheurs du domaine de la TB un soutien financier et technique. Le fonctionnement du comité de concertation éthiopien sur la recherche relative à la TB a également bénéficié d'un soutien. Les comités d'éthique régionaux ont été renforcés ou créés lorsqu'ils n'existaient pas.Résultats : Cinquante-deux personnes ont été formées et ont réalisé 13 projets d'OR, dont six ont été publiés à ce jour. De plus, huit protocoles ont été soutenus par des subventions. Les comités d'éthique ont été renforcés dans toutes les régions.Conclusion: L'initiative a formé des participants de toutes les régions et ceux-ci ont terminé avec succès toutes les étapes du processus d'OR. Le succès de ce programme peut être attribué à une approche sous forme de travail d'équipe, à un apprentissage sur le tas, au programme intégré de mentors et à une forte appropriation nationale.

Marco de referencia: La práctica de investigación operativa dentro del marco programático es importante en el fortalecimiento del control de la tuberculosis (TB). En el 2012, el Ministerio Federal de Salud de Etiopía puso en marcha una iniciativa encaminada a crear capacidad de investigación operativa (OR).Objetivo: Desarrollar capacidad sostenible de OR en el país mediante una iniciativa plurianual.Método: La iniciativa se formuló en cooperación con expertos regionales, nacionales e internacionales. Varios equipos, en representación de las regiones de Etiopía, llevaron a cabo proyectos de OR que respondían a las prioridades nacionales y regionales. Con el propósito de aprovechar las competencias locales y mejorar la sostenibilidad se incorporó al proyecto un programa interno de capacitación de tutores. Se reforzó la capacidad existente mediante un plan de subvenciones otorgadas por concurso y destinado a suministrar ayuda económica y técnica a los investigadores en el campo de la TB. Asimismo, se prestó apoyo al funcionamiento del Comité Asesor de la Investigación sobre TB en Etiopía. Se reforzaron los comités de ética existentes y donde no existían se crearon nuevos comités.Resultados: Se capacitó a 52 personas y se llevaron a cabo 13 proyectos de OR, de los cuales seis han publicado sus resultados hasta la fecha. Se financiaron además ocho protocolos por conducto de las subvenciones. Se reforzaron los comités de ética en todas las regiones.Conclusión: Gracias a esta iniciativa se capacitó a los participantes provenientes de todas las regiones y se logró la compleción de todas las etapas del proceso de OR. El éxito del programa se puede atribuir a la estrategia de equipo, el aprendizaje en la acción, la integración del programa de tutoría y a una decidida apropiación nacional de la iniciativa.