Download Background Document - TB Grant

NEW FUNDING MODEL GRANT
Background
As New Funding Model (NFM) is not a totally new grant and built upon (Single Stream of
Funding) SSF grant with some expanded scope of work. Both PRs (NTP and Mercy Corps)
continued with the existing SRs with some changes in implementation arrangements, in
addition to inducting new SRs and implementing partners, as summarized below:
National TB Control Program Pakistan (PR 1):
In SSF (Single Stream of Funding) Grant, three non-governmental organizations were working
as SRs in MDR-TB objective:
1. Association for Community Development (ACD)
2. Association for Social Development (ASD) and
3. Indus Hospital Karachi (IHK)
Four Provincial TB Control Programs (PTPs) Punjab, Sindh, Khyber Pakhtunkhwa (KP) and
Balochistan have also been inducted as SRs from Jan 2014, in the context of devolution of
Ministry of Health, continued in same objectives with enhanced role in PPM to support large
private hospitals and NGO networks including Pakistan Anti TB Association (PATA), Agha Khan
Health Services Pakistan (AKHSP), Al-Khidmat Foundation (AKF), Provincial Public Health
Initiative (PPHI) and Punjab Rural Health Support Program (PRSP).
PATA, AKHSP and PLYC have been SRs for different GF grants and are managing large number
of health outlets. PPHI is a new entrant but is already involved in TB management at BHU level
in Sindh.
Greenstar Social Marketing (GSM) is one of the largest contributing private sector partner
and had been SR in R-3, implemented Social Franchising model of care in 5 metropolitan cities
with outstanding performance, then worked as Co-PR with NTP in R-8 (currently in closure
phase) to strengthen the Drug Management System, and was SR of MC PR in R-9/SSF
implementing PPM intervention in 22 districts across Pakistan.
NTP & MC have adopted a cluster approach in PPM for cost effective program management,
keeping its implementation partners in a set of districts thereby making a cluster. However,
in case of Greenstar mostly large metropolitan cities have been assigned. To summarize, in
fact GSM role in PPM TB DOTS has been enhanced in NFM.
Under NFM, Greenstar Social Marketing (GSM) has been taken as SR of NTP in 13 districts.
Although, the number of districts has been reduced but total population in these 13 allocated
districts is 63 Million which is at least 10 million more than that of total population of 22
districts (53 Millions) assigned to GSM in SSF grant while working as SR of MC.
The number of missing TB cases in these 13 districts is 76,000 which is at least 20,000 more
than those in 22 districts (56000) assigned to GSM in SSF grant. Keeping in view the strength
of GSM in Urban cities it is expected that at least 42,000 cases shall be contributed through
this investment in two and a half years. It is pertinent to mention that GSM has been assigned
1,500 chest camps/year (out of total planned @ 3000/year) for active case finding in these 13
districts for enhanced case detection and have also been provided with appropriate human
resource.
Four Regional TB Control Programs (RTPs) Gilgit-Baltistan (GB), FATA, Islamabad Capital
Territory (ICT), and AJK are also working with NTP as implementing partner in their respective
territories.
Mercy Corps (MC) – PR 2:
MC is implementing PPM part of the grant in 71 districts of Pakistan working with four SRs
including
1.
2.
3.
4.
Association for Community Development (ACD)
Association for Social Development (ASD)
Bridge Consultants Foundation (Bridge), and
Pakistan Lions Youth Council (PLYC)
There are two new proposed SRs; i) Marie Adelaide Leprosy Center (MALC) and ii)
Strengthening Participatory Organization (SPO) which has a large geographic presence at the
community level in the province of Balochistan where very few other non-governmental
organizations currently work.
MC has been working as PR under the Global Fund grants since 2007, when it was selected as
the non-governmental PR for the first time in Pakistan. Since then, MC has managed the
Round 6 TB grant, the consolidated grant (R-6 & R-9) and the single stream of funding (SSF)
grant for TB.
Epidemiology of tuberculosis in Pakistan
Tuberculosis (TB) is a major problem of public health in Pakistan. Pakistan ranks 5th among
the 22 high TB burden countries as well as among 27 high multi-drug resistant (MDR) TB
burden countries. It accounts for approximately 60% of the TB burden of the Eastern
Mediterranean Region (EMR) of the World Health Organization (WHO).
a.1: Incidence and Prevalence: A nationwide population-based TB prevalence survey was
carried out in 2010/2011 that involved nearly 106,000 persons based on survey results,
estimated TB prevalence rate (all forms and all ages) is 342 cases in 100,000 population
(95% CI: 284- 406 ) and TB incidence rate is 275 TB cases per 100.000 populations. (95% CI:
205-357).
TB disease prevalence survey’s estimate of 342/100,000 implies that between 520,000 and
740,000 individuals have active TB in the country at any given time. The estimated incidence
of 275/100,000 means that 288,910 new TB cases notified in 2013 represented only about
58% of the best estimate of incident TB cases.
TB prevalence is higher in males (365 versus 247 in females) and that there is a linear trend
of the TB prevalence associated with the age reaching 1.3% in individuals aged 65 years, which
is nearly seven times higher than in those belonging to 15-24 year age group.
a.2: TB Mortality: The WHO estimates that the mortality rate of TB was 27 deaths per 100,000
populations in 2013(Global TB Report 2014 online version); this shows that the TB mortality
in Pakistan has declined by 60% in comparison to 1990 which was 69/100,000.
a.3: Case registration/ Case Notification: Pakistan notified 298,446 TB cases of all forms in
2013 (164 cases per 100,000 population), compared to 20,707 in 2001. The new and relapse
cases notified from among these (288,910) represent about 58% of the estimated incidence.
Similarly, in 2013 a total of 111,682 new sputum smear positive cases were detected,
compared to 6,703 in 2001. A similar number of new cases reported were sputum smear
negative (118,279), and a further 52,646 new extra-pulmonary cases were also reported. The
ratio of pulmonary to extra-pulmonary cases among new TB patients has declined slightly in
the last four years.
The percentage annual change in TB notifications and in notification rate in general
population have both decreased over time, although the trend appears to have started to pick
up slightly again in the last couple of years. The flattening in notifications has occurred in all
age-groups, both sexes and all over the country. This phenomenon is commonly attributed to
a static number of private health care providers in the country that contribute to overall TB
case notifications in recent years, a claim supported by the stagnation over time of cases
originating from the private sector.
a.4: Age and Gender distribution: The male to female rate ratio among notified TB cases in
Pakistan is close to 1, being 1.1 in new smear positive cases, 1.0 in smear negative and 0.8 in
new extra-pulmonary cases. It also decreases with age, being >1.5 in the elderly, 1 in young
adults and 0.5 in children. Among adults the ratio appears to have decreased since 2001.
Moreover, among notified smear-positive TB cases, the proportion of females tends to be
higher in age-groups below 35 years and much higher in those below 15 years of age.
NTP Data show that TB is affecting mainly young adults and productive age groups. Among
notified smear-positive TB cases 65% are aged less than 45 years, nearly 80% less than 55
years and 75% between 15 and 55 years. However, age distribution of smear-positive TB cases
notified from 2001 to 2013 indicates a very slight shift of TB notification towards older age
groups. In 2013, among the total cases notified about 10% were children less than 15 years
of age. The last population-based TB prevalence survey, carried out in 2010/2011, reported
that 1.3% of persons aged 65 years and above had active TB
a.5: Geographic Distribution: The notification rate varies across the provinces and the
regions: in 2013, the highest notified rate (all forms of TB) was in Punjab (189 per 100,000
populations) and the lowest in Baluchistan (79 per 100,000 population). On average 60% of
TB cases (for both any form and smear-positive TB) are notified in Punjab, 20% in Sindh and
13% in Khyber Pakhtunkhwa.
There is some relationship observed between the number of TB diagnostic centers per district
and the number of cases notified in the district. The epidemiological report of Pakistan shows
this association in Punjab in 2013, where the variation in number of health centers between
districts appears to explain much of the fluctuation in cases (although the numbers of centers
is also correlated with the population size in the districts).
There is substantial regional variation in the ratio of pulmonary to extra-pulmonary disease,
with apparently higher levels of extra-pulmonary disease being reported in the northern areas
of the country
a.6: MDR-TB: First National drug resistance survey was conducted in 2012/13. Based on
preliminary data analysis, it is estimated that proportion of MDR is 4.3% (9900) among new
cases and 19% (3100) among retreatment patients and the number of MDR TB cases among
notified pulmonary TB cases was 13000 in 2013 (WHO Global Tuberculosis Report 2014).
Programmatic management of drug resistant TB started with enrollment of 210 patient in
2010 increasing to 1570 patients in 2013. Table1 below show patient enrollment over last
four years and treatment success rate of two annual cohorts completed. A high treatment
success rate of >70% was achieved.
First and Second line Drug susceptibility testing is done of all patient enrolled and empiric
treatment is subsequently modified based on the DST pattern. High Fluoroquinolone
(Ofloxacin) resistance is constant feature of patient enrolled and is reported to be 44 %(
2010), 45% (2011), 45% (2012) and 41% (2013) with impact on treatment regimen, duration
and cost.
In 2013, Patient enrolled in PMDT (#1570) represented only 12% of the total incident drug
resistant TB cases.
a.7: TB/HIV Co-infection: Pakistan is a low HIV burden country. The prevalence of HIV
infection in general population is less than 0.1%. However, the trend of HIV infection has
shifted from a low prevalence state to concentrated epidemic state among well identified key
populations at high risk where, in some of them, the HIV prevalence is more than 5%. The
NTP’s existing sentinel surveillance system has indicated that the prevalence of HIV infection
among TB patients was 0.3 and 0.4 percent in 2012 and 2013.
Goals
1. Contribute to achieving the goal of the national strategy to control TB in Pakistan
which is to reduce by 50% the prevalence of TB by 2025 in comparison to 2011.
2. Contribute towards decreasing the prevalence, by at least 5% per year from 2018
onwards, the prevalence of MDR-TB among TB patients who have never received any
TB treatment.
Objectives
1. To increase TB case notification (all forms) from 61% of estimated incident cases in
2013-14 to 71% of estimated incident cases by 2017 while maintaining treatment
success rate at 91%.
2. To enhance MDR-TB enrollment from 18% of estimated cases in 2013-14 to 23% of
estimated by 2017.
3. To increase the number of TB patients who are screened for HIV infection from 3% in
2013-14 to 10% by 2017.
Scope of Work
The current funding request has been built upon the existing SSF grant. All the activities of
SSF grant have been suggested to continue in the NFM with addition of some new activities
mainly focusing on PPM to augment the current interventions. These activities will
complement the existing ones, and will help optimize the yield hence enabling NTP to achieve
the desired impact by more judicious use of grant funds.
Implementation efficiencies have been worked out in the area of TB-HIV Collaboration,
where, the intervention will be jointly managed at ART Centers under NACP for integrated
case management for TB-HIV Co-infection, and Sentinel Sites established by NTP in TB DOTS
clinics providing screening services for HIV after counseling and rapid testing. Further, both
HIV and TB programs have agreed to merge their individual national reference laboratories;
hence, sharing their technical, human and physical resources to complement each other’s
objectives and gain maximum efficiencies. Both programs will provide technical assistance in
their respective areas conduct joint monitoring and sharing the data on regular basis through
coordination mechanism established under the current grant, which will further be
strengthened through involvement of People Living with the diseases.
The focus of NFM grant is to enhance TB care for sensitive and drug resistant TB by scaling
up case finding and ensuring treatment for all cases diagnosed including those suffering from
TB/HIV co-infection , and strengthen TB program’s management capacity.
Increase TB detection (and treatment): Significant progress has been made in TB control in
Pakistan however, only half of the estimated incident TB patients are currently being
identified and treated leaving behind a large number of missed cases, leading to high
transmission. Activities proposed for increase case finding are focused on screening more
patients suspected of TB in public and private sector, improving access to quality assured
diagnostic services and uninterrupted supply of drugs. It is estimated that suspect screening
will increase from current (in 2013) 800,000 per year by up to fourfold (> 3 million) in 2017
and case detection will increase from 58% to 71% during the same period. Increase in case
finding will be achieved through: i) Better access and improved utilization of current public
sector health infrastructure and TB diagnostic facilities and ii) improving coverage by
engaging private sector other healthcare providers. In addition, active case finding
approaches and use of new diagnostic tool are proposed for early diagnosis of tuberculosis in
vulnerable (women and children) and high risk population (urban slums, PLHIV) in
communities.
It is estimated that approximately 910,000 new cases will be identified (July 2015-Dec 2017)
and 91% of these will be successfully treated. Increase in case detection and successful
treatment will lead to decrease in TB transmission and TB-related mortality in the population
over the coming years.
Drug-resistant TB (DR-TB): It is estimated that there were 13,416 DR-TB cases among TB cases
notified from July 2013 and June 2014. In 2013-14, 2446 DRTB case were detected and put on
treatment which represent 18% of estimated incident MDR-TB cases. Through this
investment, further scale-up of programmatic management of DR-TB will take place to
diagnose and put on treatment 32% annual estimated incident cases , which would mean
that in total 13142 DRTB - patient will be diagnosed and enrolled on treatment including 8215
from indicative amount and 4927 from above allocation .
TB/HIV co-infection: The current GF-supported TB/HIV collaborative activities will be
intensified. Screening of TB patient for HIV will be increased from 3% to 10% and screening
PLHIV for TB will be increased up to 90% by establishing linkages and improving access to HIV
screening and TB diagnosis for people living in cities with known concentrated epidemics .
Early diagnosis and treatment will reduce the number of deaths in PLHIV from TBHIV coinfection
TB program’s management capacity: NTP’s capacity will be further strengthened through
robust epidemiological surveillance and M&E. In addition, financial and procurement and
supply chain management capacity will be further enhanced and drug management
information system will be made more efficient.
It is important to highlight that approximately 56.4% of the all type TB cases are estimated
to be identified (and treated) through Global Fund and rest of need will be met through
domestic funding(30%) and partly through WHO emergency grant for drugs (13.5% of FLD).