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Regional Strategic Plan for
TB Control 2002 – 2006
World Health Organization Regional Office for South-East Asia, New Delhi
S T N E T N O C
EXECUTIVE SUMMARY INTRODUCTION PROGRESS MADE TOWARDS GLOBAL TARGETS ISSUES AND CHALLENGES GOALS AND OBJECTIVES PRIORITY STRATEGIES AND INTERVENTIONS FOR THE NEXT FIVE YEARS Expanding DOTS While Ensuring Quality of Services Enhancing Case Detection Addressing Current and Emerging Concerns INDICATORS AND TARGETS DOTS Expansion Cure Rates Case Detection Rates
4 6 9 14 17
18 18 22 23 25 25 27 27
PROGRAMME MANAGEMENT AND MANAGEMENT PROCEDURES Regional Level Coordination WHO Country Collaboration Mechanisms Mainstreaming of TB Control Activities Management Information System RESOURCE AND SUPPORT SYSTEM MONITORING AND EVALUATION Country and Regional Progress Reports Country Programme Monitoring Missions and Inter-country Reviews Annexes Budget Requirements Regional Office: 2002-2006 Planning for 2002-2003: Resource Requirements and Current Partnerships at Country Level 37 34 33 29 29 29 30 31 32 33 33
Contents
Executive Summary While considerable progress has been made in recent years with implementing the DOTS strategy in all the Member Countries of the South-East Asia Region, several issues require to be addressed in order that the Region achieves global targets for tuberculosis control within the next five years. The challenges that impede sustainable expansion of quality-assured DOTS services are insufficient political commitment and resources for TB control, inadequate technical and managerial capacity within national programmes, suboptimal case management practices within both public and private health sectors and a low community awareness of available health services including DOTS. These have been compounded by social factors, poverty and increasing migration, leading to homelessness and a resultant compulsion to live and work in high-risk environments. The advent of HIV and MDR-TB in some parts of the Region only serve to underline the urgency of further expanding and intensifying DOTS in the Region.
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The priorities are to continue to expand while ensuring quality DOTS services, enhance case detection and to urgently address current and emerging issues. Advocacy to enhance political commitment for increased resource allocation for TB control must be undertaken, while simultaneously building the technical and managerial capacity of national programmes to implement and expand DOTS more effectively through improved laboratory and treatment services, and strengthening logistics, reporting and monitoring mechanisms. Case detection and case management must be improved through increasing community awareness and participation in DOTS programmes, collaboration with other disease control programmes, other government sectors and through partnerships with the private health sector, teaching institutions, business and industry to increase access and utilization of quality-assured DOTS services. A unified approach to the management of TB–HIV is envisaged with several TB–HIV collaborative activities being supported in Member
Countries to combat the inextricably conjoined epidemics of TB and HIV. Operational research to identify replicable innovative interventions to more effectively deliver DOTS in the diverse health settings in the Region needs to be encouraged. The Regional Strategic Plan for TB control in South-East Asia is a comprehensive document outlining the strategies and approaches that will be adopted to meet the challenges of achieving the objectives of universal coverage with quality DOTS services with at least 85% cure rates and 70% case detection in all Member Countries in the Region within the next five years. Indicators and targets have been defined to measure progress through 2002-2006 and the resources required identified. Given long-term commitment and resources to implement the activities envisaged in the plan, the South-East Asia Region could be well expected to achieve global targets by 2006.
Introduction
The South-East Asia Region accounts for nearly 40% of the world’s burden of TB, with 3 million new cases and nearly three-quarter of a million deaths occurring annually due to the disease. Over 95% of cases and deaths due to TB in the Region are reported from the five high-burden countries in the Region: Bangladesh, India, Indonesia, Myanmar and Thailand. India alone accounts for nearly a third of the global burden of disease. The incidence of disease is the highest in the age group 15-54 years, seriously affecting social and economic development; the financial loss sustained in the Region is estimated at US$ 4 billion per year. The spread of HIV in the Region and the emergence in recent years of multi-drug resistant strains of tuberculosis pose additional threats. A total of 445 296 cases (all forms of TB) and 235 511 (smearpositive cases) were notified in the year 2000. The overall DOTS detection rate in the Region was 34%. DPR Korea, India and Myanmar reported the largest increases in case notifications, while these have remained stable in the remaining countries, with the exception of Maldives where the estimates have been revised
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Global Burden of Tuberculosis by WHO Regions - 2002
downwards based on trends in that country. The proportion of new smearpositives cases out of all those notified under DOTS has remained steady at around 53%, higher than the proportion (28%) among cases not registered under DOTS, reflecting improvements in the quality of diagnosis under DOTS. All Member Countries in the Region have been reporting case notifications regularly; reporting from DOTS areas is complete with the exception of Indonesia and Thailand, largely due to transitions under the health reform process. A total of 63% of infectious cases notified were in the age group 15-54 years with the number notified peaking in the age group 25-44 years among
males and 15-34 years among females. The male to female ratio remained 2:1 among these cases. In some areas in the Region, up to 30-40% of TB patients are co-infected with HIV and between 55-70% of P LWHA develop active TB. It is estimated that nearly 3 million people in the Region are currently co-infected with HIV and TB. There is a paucity of data on drug resistance in the Region. While several small studies have been carried out independently in several countries, nation wide surveys have been undertaken only in Nepal and Thailand. India, Nepal and Thailand participated in the WHO-IUATLD global project on anti-TB drug resistance between
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1995 and 2000. Multi-drug resistance levels among new smear positive cases ranged from 1.4% (Nepal) to 3.4% (Tamil Nadu, India). Overall MDR-TB rates among new cases in the Region are estimated to be under 2%; among previously treated cases, levels ranged from 7.4% (Nepal) to 25% (Tamil Nadu, India). Expansion of the DOTS strategy remains a top priority for the Region. Crucial issues are: continued mobilization of political commitment to ensure allocation of adequate resources both human and financial; forging and sustaining inter sectoral partnerships to enhance access to and quality of services; ensuring an uninterrupted and regular supply of good quality drugs and laboratory reagents, and social marketing of DOTS to increase community participation and
involvement in national efforts for TB control. Recent events at the global level offer considerable opportunities to accelerate and intensify DOTS in the Region. Political commitment following the Okinawa summit, the Amsterdam Declaration and the Washington Commitment is high. The increased resources made available through bilateral and multilateral agreements, and through mechanisms such as the GFATM must be effectively utilized. A Coordinated plan that articulates the technical, managerial, social and political strategies towards clearly stated goals for TB control is a primary requisite. It is with this aim in view that the Strategic Plan for TB Control in the South-East Asia Region has been prepared.
Recent events offer considerable opportunities to accelerate and intensify DOTS in the Region. Political commitment following the Okinawa summit, the Amsterdam Declaration and the Washington Commitment is high.
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Progress made towards global targets
Considerable progress has been made since the adoption of the DOTS strategy for TB control by all Member Countries in the Region. Currently, DOTS coverage extends to over 60% of the Region’s population; under the DOTS strategy, over two million patients have so far been treated with a success rate of around 80% under programmatic conditions in areas where the strategy has been applied. The quality of diagnosis has been good; however the number of cases detected is still low at around 34% of estimated cases. Of the five high-burden countries in the Region, Bangladesh has covered virtually the entire country with DOTS; case detection is being intensified through several new initiatives. India has expanded rapidly to over 460 million people by mid2002 and will cover 80% of the population by 2004; the quality of implementation has been excellent due to the systematic approach adopted. Indonesia has expanded DOTS to cover 90% of the country and has demonstrated strong political commitment; technical strengthening is under way. Myanmar has implemented DOTS in 85% of the country and, given the
DOTS Population Coverage in the SEA Region
support recently made available, will expand to cover the entire country by 2003. Thailand has achieved over 90% coverage; implementation of DOTS through an integrated approach under the new health scheme, DOTS in the urban areas, and supervision and reporting are being improved in order to obtain better treatment outcomes. Among the low burden countries, Bhutan has achieved complete population coverage; improving the delivery of DOTS in the difficult terrain is a challenge. DPR Korea is rapidly expanding DOTS; current population coverage stands at 66%. Maldives achieved full coverage in 1995 and has maintained global targets since. Nepal has implemented DOTS successfully in over 90% of the country and will achieve global targets by 2002. Sri
Lanka has achieved 74% population coverage with DOTS; domiciliary DOTS has been introduced in 13 districts; the national programme is expected to achieve global targets between 2003-2004. Recognizing that tuberculosis continues to be a significant health concern and that the DOTS strategy must rapidly be made universally available, several activities have been undertaken to focus the attention of policy-makers in the Region on tuberculosis. Tuberculosis was one of the key topics discussed by the health ministers in Myanmar in August 1999 and by the Health Secretaries at their meeting in New Delhi in February 2000. The five highburden countries participated in the Ministerial conference on TB and
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TB Control – Status of DOTS in the Region Country Population DOTS in millions Population coverage July 2002 Millions % New Sputum smear + TB cases % DOTS Case Detection (2000) % Treatment success in DOTS areas (2000)
Est. Annual Incidence (National) 149445 1281 17510 830667 267017 76 39096 21482 4973 38638 1369212
Notifications in DOTS areas (2000) 35644 347 4572 95012 50633 65 17254 12472 1758 17754 235511 24% 27% 26% 11% 20% 86% 48% 58% 37% 46% 34% 83% 90% 91% 84% 87% 94% 81% 87% 77% 77% 84%
Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand* Total
130 0.65 23 1010 209 0.27 45 23 19 62 1522
124 0.65 15 460 188 0.27 38 20 18 53 916.92
95 100 66 46 90 100 85 85 95 85 60
* data for 1999-2000
Sustainable Development in March 2000. Following this, health ministers in the SEA Region called for WHO assistance in developing five-year plans of action for TB control and for initiating steps for cross-border disease control, including TB. The Regional Office developed guidelines for formulating these plans and undertook missions to assist countries in developing their fiveyear plans for TB control. Joint plans of action for initiation of integrated disease control activities for TB, HIV, Malaria & Kala-azar in the adjoining border districts between Bangladesh,
Bhutan, India, and Nepal have been drawn up and will be carried forward in 2002. The Thai-Myanmar border programme for communicable disease control is already in place. Collaboration with ASEAN and SAARC in the area of TB control has been established. The recognition that both private sector and NGOs have a crucial role to play in national TB control efforts has led to several initiatives being taken. Several public-private partnership pilot projects in the Region have paved the way for
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paramedical disciplines: these will now be revised to allow fresh graduates a better understanding of national TB control programmes, as will the setting up of DOTS training and demonstration centres in several medical schools in the Region. WHO has continued to provide technical support to all Member Countries in planning, implementation and monitoring national TB control programmes through regular and shortterm international consultants and through national programme officers and consultants to assist national TB programme staff. A network of laboratories to undertake quality assurance of microscopy services and drug resistance surveillance has been identified. Several Member Countries of the South-East Asia Region (SEAR) have applied to the Global Drug Facility and Myanmar was among the first to benefit. In addition, several Regional training courses on the technical and operational aspects of TB control have also been
the development of policy guidelines and a framework for private sector involvement in TB control. Many successful models are expected to be widely replicated. Partnerships with medical schools have similarly been supported to include the teaching and practice of DOTS in the medical teaching institutes in Member Countries. National level meetings to orient the medical academia and to obtain their active involvement in National TB control programmes are being held in several Member Countries. Support has similarly been provided for a review of teaching materials being used to train undergraduates and postgraduate students of medicine and the
Several technical and training materials have also been developed on supervising TB control activities, resource mobilization, cross-border disease control and leadership and strategic management.
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held: a) comprehensive training on TB control, b) laboratory methods for smear microscopy and drug resistance assay, c) the epidemiologic basis of TB control and d) data management, to facilitate recording and reporting at country level. Technical and training materials have also been developed on supervising TB control activities, resource mobilization, cross-border disease control, leadership and strategic
management. A compilation of NGO and private sector activities in national TB control efforts has also been prepared. Collaboration between TB and HIV control programmes has commenced in Member Countries. At the joint programme managers’ meeting in November 2000, areas for collaboration were identified and several TB-HIV collaborative activities are currently being undertaken in the Region.
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Issues and Challenges
A wide range of issues need to be addressed in order to continue to sustain and expand DOTS without compromising on the quality of programme implementation. The following challenges have been identified:
Sustaining political commitment, leadership and mobilising resources Funding remains a major constraint in several Member Countries and most are dependent on external resources. Without sufficient staff who have requisite skills to carry out activities and supervise and monitor programme performance, sustaining present implementation and further expansion may remain difficult, especially in the larger high-burden countries. Advocacy at the highest levels to ensure adequate funds from national budgets and from donor agencies and governments is therefore one of the main priorities for the Regional Office. A meeting of the Regional Partner’s Forum with broad representation from donors, UN Agencies and Member Countries
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proposed is to enhance commitment and resources for TB control in the Region.
Enhancing case detection Considerable inputs still need to be made to ensure that adequate technical expertise and infrastructure is available to allow for universal access to qualityassured laboratory services in all Member Countries. This will include strengthening national and supranational reference laboratories to undertake quality assurance of smear microscopy and surveillance for drug resistant TB. Case detection in the Region is still low at around 40% of estimated new smear positive cases. This is due both to a lack of involvement of the community and that of various health providers such as private medical practitioners, hospitals, medical schools, NGOs, as well as those practising other systems of medicine. Developing partnerships with these sectors to widen the reach of DOTS, information, education and
communication campaigns to improve utilization of DOTS services, and operational research to promote locally appropriate solutions are all essential toward reaching the 70% target for case detection.
Ensuring regular and uninterrupted supply of drugs and logistics Despite improvements in procurement mechanisms and logistics, many Member Countries continue to face problems with drug procurement and distribution, leading to imbalances or shortages in drug supplies at health centre level.
Ensuring monitoring and evaluation Complete and accurate recording and reporting from all DOTS areas in Member Countries in the Region, together with timely feedback to staff at the field level through quarterly state/ provincial/district level meetings and through annual internal reviews to make timely and relevant interventions
Case detection in the Region is still low at around 40% of all estimated cases. This is due both to a lack of involvement of the community and that of various health providers.
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populations, often homeless, are urgent priorities. While some initiatives have been taken, clear policy guidelines and plans of action for TB control in border areas for migrant populations and other vulnerable groups must be developed and implemented. Operational research to address these concerns and others, such as ensuring gender equity in accessing health, establishing DOTS services in urban areas and in hard-to-access remote regions have been initiated. Lessons learnt so far need to be used to define guidelines for wider application.
on a regular basis must be ensured. These, together with mid or end-of-term external monitoring missions are crucial to evaluate progress being made.
Addressing emerging issues TB–HIV, MDR-TB and TB in high risk and vulnerable populations Recognizing that good DOTS implementation is key to preventing the emergence of MDR-TB and to improving the quality of life among people living with HIV/AIDS, national programmes are making additional efforts to establish active collaboration with national AIDS control programmes. Cross-border migration and lack of clear guidelines for the application of DOTS among migrant and displaced
Health sector reform Several Member Countries are now integrating previously vertically run programmes such as TB control programmes within the primary health care services, while others are simultaneously decentralizing these services. Issues relating particularly to procurement, logistics, and data management need to be addressed in order to continue to implement DOTS in a cost-effective manner. Advocacy to local governments for commitment and resources to built capacity at the appropriate level are essential for decentralized management of health care.
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Goals and Objectives
The overall goal of the regional strategy for TB control is to reduce morbidity, mortality and transmission of TB, till it is no longer a public health problem in the Region. Specific objectives are: l
To achieve universal coverage with DOTS by 2005; To cure at least 85% of new sputum smear-positive tuberculosis cases detected, and to detect at least 70% of the estimated new smear-positive TB cases in the Region by 2005, and To thereby reduce the mortality from TB by at least 50% by 2010.
l
l
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Priority Strategies and Interventions for the Next Five Years The following strategies will be adopted towards meeting the stated objectives within the next five years: l
Expanding DOTS while ensuring quality of services Enhancing case detection Addressing current and emerging concerns
l
l
The following interventions will be made under each of these strategies:
Expanding DOTS while ensuring quality of services Mobilizing commitment Ensuring commitment for sustaining and increasing resources for TB control throughout the Region is a priority. l
National TB Programmes in all Member Countries have developed five-year strategic plans for TB control detailing the activities and the resources required to achieve global
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targets by 2005. These plans need to be shared with policy-makers such as health ministers, parliamentarians, and health secretaries in order to augment national commitment and mobilize the additional resources required to continue to expand and improve the quality of DOTS implementation. Efforts to forge regional and international partnerships to mobilize and optimally utilize the resources made available will be undertaken through the involvement of regional forums such as ASEAN and SAARC and through donor coordination at country level l
l
TB programme managers not only require to guide and lead the health team, but also influence policy and practice at various levels; in order to meet this need, national and intermediate level managers will receive training in leadership and management skills Increasing community ownership and participation is crucial to the success of DOTS implementation; communication strategies will need to be developed to involve civil society at large
l
Improving microscopy services Sputum smear microscopy remains the recommended method for case detection of new infectious cases amongst chest symptomatics seeking care at health facilities. This requires that services are reliably available and readily accessible to those seeking care. This can only be achieved through the development of an adequate network of microscopy centres including those laboratories in hospitals, teaching institutes, NGOs, corporate and other large employment sectors, and especially those in the private sector. Priority intervention areas include: l
The regional technical advisory group—which includes regional and international experts, national TB Programmes staff, UN agencies, NGOs and others will identify the best mechanisms to further TB control in the Region The Stop TB Regional Partners’ Forum will serve as a platform to share the concerns and needs of National TB control programmes towards mobilizing additional technical and financial resources for TB control in the Region based on the comparative advantages and areas of interest of various donor partners
l
Continued capacity building through inter-country training of
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appropriate laboratory staff and support for similar training at country level l
Assisting NTPs in assessing and strengthening the quality of sputum microscopy services in collaboration with the WHO laboratory focal point and WHO collaborating centres Establishing collaboration for smear microscopy with private sector laboratories conforming to standard guidelines Developing guidelines for and assisting with establishing quality assurance for sputum microscopy, at all designated microscopy centres and Establishing a system for external quality assessment with the designated regional supranational reference laboratory ensure compliance and follow-up till cure l
l
l
l
Enhancing treatment success The core of TB control lies in preventing transmission of disease through cure. This can only be done through ensuring the use of appropriate regimens of short-course antiTB drugs, on an uninterrupted basis and through regular supportive supervision of individual patients to
This requires that a large work force of health personnel at different levels within the public health infrastructure and in other sectors be trained comprehensively on the several aspects of TB case management; that the private medical sector be involved and that private practitioners follow national guidelines, especially in this region where this sector provides care to a significant proportion of TB patients Community ownership and participation will be enhanced particularly to improve health-
l
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seeking behaviour and adherence to treatment through identification of locally acceptable and appropriate mechanisms and l
Medical schools will be actively involved especially in the areas of pre- and in-service training, research and technical assistance to national programmes Operational research to identify ways to improve case holding and treatment supervision especially among migrant and marginalized population needs to be undertaken
l
Ensuring accurate recording and reporting Accurate and complete reporting is essential to assess the treatment outcome of every patient registered and to assess for overall programme performance at peripheral and central level. Quarterly reporting and analysis helps to establish a system of regular communication between the central and district or sub-district levels; this early analysis of data also helps to identify constraints which may then be overcome through timely and locally appropriate interventions. The following activities will be undertaken to achieve this: l
Ensuring supplies Regular uninterrupted supplies of quality drugs and consumable must be available at all levels of the health care delivery system for the success of DOTS. Reliable drug procurement and distribution systems need to be in place in all Member Countries in order to achieve this. l
The provision of assistance to establish effective data management in Member Countries will continue Capacity for recording, reporting and supervision will continue to be built through the inter-country training courses and through providing assistance for similar training at national level Assistance with adaptations in the reporting formats will be provided where required, for example additional information to be collected in specific settings such as
l
Assistance will be provided to strengthen logistics and streamline procurement procedures and l
l
Support from the Global Drug Facility will be obtained for national programmes in countries which face resource constraints for drugs
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in areas of high HIV prevalence or in cross-border areas Supervision, monitoring and evaluation Continuous monitoring and supervision at all levels needs to be planned and implemented from the initiation of DOTS services to ensure that quality services are provided at all times and especially during a phase of rapid expansion. This will be undertaken through building capacity at country level for effective supervision, and through documentation and sharing of improvements on supervisory methods. The following will be undertaken to achieve this: l
l
External mid-term and end-of-term monitoring missions and regular programme reviews will be undertaken
Enhancing Case Detection Case detection in the Region remains low on account of several factors. While capacity within national programmes continues to be built to improve access to quality services, TB patients continue to use health care services provided in other sectors including those of unqualified practitioners. This leads to significant delays in obtaining quality care both in terms of diagnosis and treatment in addition to unnecessary expenses incurred for the ineffective treatment. Ensuring that these patients seek care and are diagnosed early and treated appropriately is crucial for the reduction of transmission of disease. This requires that several measures be undertaken: l
An assessment and strengthening of systems of data management to establish accurate and timely quarterly reporting at national, intermediate and local levels Internal quarterly and annual reviews will be supported at country level and
l
Building partnerships with NGOs, the private sector, medical schools and developing mechanisms through operational research for
Quarterly reporting and analysis helps to establish a system of regular communication between the central and district or sub-district levels; this early analysis of data also helps to identify constraints which may then be overcome through timely and locally appropriate interventions.
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involvement of local health providers of various systems of medicine l
through collaboration between the NTPs and researchers in the various sectors that are involved in health care delivery and l
Developing an effective IEC strategy through consensus and field testing in the various diverse health settings in the Region Involvement of the community through use of mass media and interpersonal methods with support from NGOs and CBOs especially to reach marginalized populations who may additionally, be at higher risk of infection and disease Building collaboration with other programmes to integrate DOTS services as part of ongoing work Establishing with the industrial and education sectors, DOTS in the workplace and in schools Supporting targeted case-finding activities so as to detect cases at an early stage among institutionalized and vulnerable populations such as migrants Supporting operational research as an integral part of national programmes to design and evaluate locally relevant interventions
Documenting successful initiatives to promote wider application of these
l
Addressing Current and Emerging Concerns Several issues and concerns such as the emergence of drug resistance and a high prevalence of HIV in some areas in the Region call for additional strategies to be developed and adopted. Mechanisms to address health sector reform in the context of DOTS need to be developed. The following activities will be undertaken to address these issues: MDR-TB l
l
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l
Establishing mechanisms for drug resistance surveillance (DRS) and sharing this data with NTPs for programme purposes Networking among laboratories at country level and developing linkages with WHO collaborating centres in close collaboration with the laboratory focal point at the Regional level to undertake DRS
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l
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TB-HIV l Developing a regional framework so as to develop a coordinated approach to managing TB-HIV l
l
Continuing to support implementation of joint TB-HIV projects at country level
Supporting cross-border interventions integrated with other priority communicable diseases including TB and HIV in six countries in the Region
Summary of Key Interventions planned – 2002-06 Country Key interventions/activities planned 2002-06 High burden: in rapid w Strengthening national programmes to sustain, further expansion phase expand and improve the quality of implementation India w Increasing case detection and treatment outcomes High burden: DOTS w Improving drug procurement and distribution procedures expansion > 85% to ensure uninterrupted supplies of quality drugs Bangladesh w Mobilizing inter-sectoral partnerships Indonesia w Establishing cross-border collaboration for TB control Myanmar Thailand w Developing donor coordination through high level meetings
w Strengthening social mobilization and community participation in TB control Low/intermediate burden: w Capacity building of national programmes for sustaining and improving case finding and treatment outcomes in rapid expansion phase DPR Korea w Expanding/improving DOTS implementation particularly Sri Lanka in remote and/or border areas Low/intermediate burden: w Strengthening recording, reporting, monitoring and DOTS expansion >85% supervision Bhutan w Enhancing social mobilization and community Maldives participation in TB control Nepal w Establishing cross-border collaboration for disease control (Bhutan, Nepal)
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Indicators and Targets
DOTS Expansion This is indicated by the percentage of the country’s population who have been provided access to DOTS. The target is to achieve 100% coverage by 2005. To measure progress towards this target, the following process indicators will be used: Political commitment l
Proportion of Member Countries who have a policy document and clear plan for TB control in the next five years Proportion of Member Countries who have allocated sufficient human and financial resources for TB control Proportion of Member Countries who have adequate numbers of skilled staff in place at all levels in DOTS areas and Proportion of Member Countries with donor coordination or country cooperation strategies in place
l
l
l
vulnerable/marginalized populations (such as migrants, refugees etc.) l
Proportion of Member Countries with established effective community participation in DOTS
Ensuring regular supplies of quality drugs l
Diagnosis and treatment l
Proportion of Member Countries with effective drug procurement and logistics systems in place
Proportion of population in Member Countries with access (as per national guidelines) to DOTS smear microscopy and treatment centres Proportion of Member Countries with quality assured microscopy services in place Proportion of Member Countries with health facilities in other sectors such as the private sector, medical teaching institutes, NGOs involved in DOTS services Proportion of Member Countries with cross-border disease control programmes including DOTS in place where relevant Proportion of Member Countries with special projects to address
Recording and reporting l
l
Proportion of Member Countries with efficient data management to ensure complete and accurate reporting
Monitoring and surveillance l
l
Proportion of Member Countries with regular annual, mid-term and end-of-term monitoring of programme performance and Proportion of Member Countries with nation-wide drug resistance surveillance in place
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l
Current and emerging issues l
l
Proportion of Member Countries with linkages with other disease control programmes especially between TB and HIV programmes
26 Regional Strategic Plan for TB Control 2002-2006
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l
Proportion of Member Countries with framework and guidelines to plan and undertake TB-HIV collaborative activities Proportion of Member Countries with training of intermediate level NTP staff in management, interpersonal communication and leadership skills and Proportion of Member Countries undertaking operational research in priority areas
positive cases of TB detected and to detect at least 70% of all estimated new smear positive cases. The indicators for these are as below: Treatment success Rate The proportion of smear positive TB patients who successfully complete treatment; the target for this is at least 85%. Case Detection Rate The proportion of smear-positive cases detected out of all those estimated; the target for this is at least 70%.
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l
The other two targets are to achieve 85% treatment success among new smear DOTS Expansion: Indicators and Targets Indicators 1. POLITICAL COMMITMENT Proportion of Member Countries with a policy document and clear plan for TB control in the next five years Proportion of Member countries with sufficient financial resources allocated for TB control on a sustainable basis Proportion of Member Countries with adequate numbers of skilled staff in place at all level in DOTS areas Proportion of Member countries with donor coordination or country cooperation strategies in place 2. DIAGNOSIS AND TREATMENT Proportion of Member countries with an effective network (as per national guidelines) of smear microscopy and treatment centres. Proportion of Member Countries with Quality assured microscopy services in place At least 80% by 2003 All countries by 2002 - 2003 All by 2005 Achieved All countries by end 2002 At least 60% by 2003-2004 All countries by 2002 All by 2005
Targets 2002-2003 2005
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Indicators Proportion of Member Countries who involve > 50% of health facilities in other sectors such as the private sector, medical teaching institutes, and NGOs in National TB Control Programmes Proportion of Member Countries with established cross-border disease control programmes including DOTS in place where relevant Proportion of Member Countries with special projects to address vulnerable / marginalized populations (such as migrants, and refugees ) Proportion of Member countries with established community participation in DOTS including involvement in provision of DOTS 3. ENSURING REGULAR SUPPLIES OF QUALITY DRUGS Proportion of Member Countries with effective drug procurement and logistics systems in place 4. RECORDING AND REPORTING Proportion of Member Countries with efficient data management to ensure complete and accurate reporting. 5. MONITORING AND SURVEILLANCE Proportion of Member Countries holding regular annual, mid-term and end-of-term monitoring using WHO recommended indicators Proportion of Member Countries with nationwide drug resistance surveillance in place 6. CURRENT AND EMERGING ISSUES
Targets 2002-2003 2005 At least 50% by 2003 At least 80% by 2005
In all six identified countries by 2003 At least 60% by 2002-2003 At least 70% by 2003 All by 2005
All by 2005
All countries by 2002
All by 2005
All countries by 2002
All countries by 2003 At least 50% by 2003 At least 70% by 2005
Proportion of Member Countries with a framework and 90% by guidelines to plan and undertake TB-HIV collaborative activities 2002 - 2003 Proportion of Member Countries who have adequate capacity to effectively undertake operational Research in identified priority areas Cure Rates Proportion of Member Countries with treatment success rates >85% for new smear-positive cases under DOTS Case Detection Rates Proportion of Member Countries who achieve case detection >40% by rates >70% of all new smear-positive cases estimated annually 2002 All by 2005 All countries by 2002 - 03 50% by 2003 70% by 2005
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Programme Management and Management Procedures Regional Level Coordination A Regional Partners’ Forum to mobilize commitment and resources to intensify and further expand DOTS in the Region is planned for early next year. A Regional technical advisory group comprising of experts in the field of tuberculosis, programme staff and donor partners in the Region has been constituted to promote, advise on and monitor progress with TB control in the Region.
WHO Country Collaboration Mechanisms The Regional Office provides support for several initiatives in the Region through three professional staff at the Regional Office and several short-term consultants who have assisted with missions in Member Countries. Country support is also provided through in-country medical and technical officers and a team of national consultants on contractual service. The following activities have been supported at country level: Joint plans of action for initiation of disease control in adjoining border districts between Bangladesh, Bhutan, India, and Nepal
have been drawn up and will be carried forward in 2002. The Thai-Myanmar border programme for disease control is already in place. Assistance has been provided to develop a network of laboratories for smear microscopy in several Member Countries and mechanisms to establish quality assurance of microscopy services and for drug resistance surveillance have been identified. Several Member Countries of SEAR will receive assistance through the Global Drug Facility to ensure regular supplies of quality drugs and Myanmar was among the first countries to have benefited. The recognition of the importance of effective collaboration with other sectors led to several partnership initiatives in the Region. The active involvement of the private health sector has resulted in several public-private partnership projects in the Region and the development of policy and planning for
expansion of successful models of public-private partnerships in Member Countries. Partnerships with medical facilities in Member Countries have similarly been initiated to include teaching and practice of DOTS to undergraduates and postgraduates in medical schools in the Region and to actively involve these teaching facilities in providing assistance to national TB control programmes. Collaboration between TB and HIV control programmes has commenced in several Member Countries. Operational research in priority areas is also being supported. Besides these, several regional training courses on the technical, operational and management aspects of TB control have also been held and several technical and training materials developed for use by national TB control programmes in the Region.
Mainstreaming of TB Control Activities In addition, the HIV-STB Unit at the
The active involvement of the private health sector has resulted in several public-private partnership projects in the Region and the development of policy and planning for expansion of successful models of public-private partnerships in Member Countries.
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Regional office collaborates with several other Units at the Regional Office which focus on integrated disease control, laboratory services and quality assurance, drug and disease surveillance, research, IEC, etc. in order to promote and provide support for TB control within the Region in these areas.
Management Information System The Regional Office has provided assistance in developing and establishing data management systems to facilitate recording and reporting on DOTS implementation in Member Countries.
31 Regional Strategic Plan for TB Control 2002-2006
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Resource and Support System
TB control in the South-East Asia Region will require that the government, private and NGO sectors as well as community groups become involved in the national effort. In the endeavour to support countries to achieve this successful collaboration, WHO regional and country offices work closely with other stakeholders and assist with building capacity for DOTS implementation at inter-country and country levels. An assessment of personnel needs and areas in which technical strengthening is required has been carried out. Support for procurement of drugs and supplies and management of funds coming through the Regional Office is carried out through the established WHO system, which will have to do more, given the needs that may emerge in the future. The financial resources required at the Regional Office level are listed in Annex 1.
Dummy Pix
Monitoring and Evaluation
Country and Regional Progress Reports Quarterly and annual reports on case detection, smear conversion, cure and treatment success rates for TB cases notified in Member Countries are received from countries regularly. These reports provided by national programmes form the basis for feedback and to identify the necessary interventions or additional support required. These reports are also used to compile the annual Regional Report on TB control and the WHO Global Report on TB Control.
Country Programme Monitoring Missions and Inter-country Reviews Monitoring missions and national reviews continue to be carried out in several Member Countries to document progress and to advise on key future actions required. Programme staff from Member Countries benefit from participating in inter-country programme reviews in the Region and from the exchange of information and sharing of experiences at the annual joint TB-HIV programme managers’ meetings held annually.
Annex 1 Budget Requirements Regional Office: 2002-2003 (US$) Programme Areas Human resources and coordination Broad Activities Regular RO and Country staff Short term consultants Administrative Staff Regional technical advisory working group meetings Meeting of Regional Partners Forum Annual Meeting of TB/HIV programme managers Meeting of regional TB-HIV working group SUB TOTAL Advocacy and Preparing Partnership advocacy / building technical materials to promote DOTS Involvement of private sector and medical schools in TB control Cross-border disease control SUB TOTAL Planned Cost 1560 000 150 000 80 000 60 000 Funding Gap 2004 150 000 150 000 80 000 35 000 Projected Costs 2005 2006
1560 000 1560 000 1560 000 150 000 80 000 66 000 150 000 80 000 72 600 150 000 80 000 79 860
40 000
40 000
44 000
48 400
53 240
100 000
55 000
110 000
121 000
133 100
20 000
20 000
22 000
24 200
26 620
2010000 40 000
530000 27 000
2032000 44 000
2056200 2082820 48 400 53 240
40 000
40 000
44 000
48 400
53 240
80 000 160000 67 000 88 000 96 800 106 480
34 Regional Strategic Plan for TB Control 2002-2006
TB
Programme Areas
Broad Activities
Planned Cost 120 000
Funding Gap 2004 60 000
Projected Costs 2005 145 000 2006 159 500
Capacity Inter-country Strengthening training course on and tools TB control development Development of materials and training on leadership and strategic management Technical support for planning, resource mobilization and implementation of DOTS in Member countries Training on standardized laboratory techniques and quality assurance Training on laboratory techniques for drug resistance surveillance Supporting models for DOTS implementation (technical materials, curriculum development) Development of regional strategy on TB-HIV Operational research SUB TOTAL
132 000
100 000
48 000
110 000
121 000
133 100
40 000
40 000
44 000
48 400
53 240
120 000
85 000
132 000
145 000
159 000
40 000
15 000
44 000
48 400
53 240
40 000
40 000
44 000
48 400
53 240
30 000
–
–
–
–
150 000 640 000
85 000 373 000
165 000 671 000
181 500 689 300
199 650 810 970
35 Regional Strategic Plan for TB Control 2002-2006
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Programme Areas Monitoring and Evaluation
Broad Activities Reviews and monitoring missions to Member Countries Strengthening disease surveillance in Member Countries SUB TOTAL GRAND TOTAL
Planned Cost 40 000
Funding Gap 2004 20 000
Projected Costs 2005 48 400 2006 53 240
44 000
60 000
60 000
66 000
72 600
79 860
100 000
80 000
110 000
121 000
133 100
2,910,000 1,050,000 2,901,000 2,963,300 3,133,370
36 Regional Strategic Plan for TB Control 2002-2006
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Annex 2 Major technical partners and type of support provided 99.6 million Current major Estimated* financial needs financial partners year 2003 and type of activities supported needs available gap 70.82 million 30 million
Planning for 2002-03: Resource Requirements and Current Partnerships
Group / list of countries
Status of plans for Main Actions needed in TB Control countries to scale up DOTS expansion
High Burden Countries
India Myanmar Thailand - BRAC, CDC, DFID DANIDA, DFB, JICA, JFAP
- WHO, KNCV, IUATLD, USAID - Overall technical support - Experts, national consultants 1 Support for drugs and logistics 2 DOTS - Technical support, implementation training, monitoring, 3 Training research 4 Research - DOTS implementation in some areas
ADB, AusAID, CIDA, DANIDA, DFB, DEID, GFATM, GDF, JICA, KNCV, NL, USAID, UNDP, WHO, World Bank
Bangladesh Indonesia
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DOTS coverage - Strengthening national <90% programmes to sustain, 5 year plans: Drafts further expand and available with improve the quality of exception of implementation Thailand Global - Increasing case detection targets by: 2005-6 and treatment outcomes - Improving drug DOTS coverage procurement and >90% distribution procedures to 5 year plans: ensure uninterrupted available Global supplies of quality drugs targets by 2005-6 - Mobilizing inter-sectoral partnerships - Establishing cross-border collaboration for TB control - Donor coordination and resource mobilization - Strengthening social mobilization and community participation in TB control
Group / list of countries
Status of plans for Main Actions needed in TB Control countries to scale up DOTS expansion
38 Regional Strategic Plan for TB Control 2002-2006
TB Bhutan: WHO DPR Korea: WHO, CIDA, GFATM Maldives: WHO, Nepal: WHO, JICA SAARC - Capacity building of WHO, CIDA, JICA national programmes for SAARC: technical sustaining and improving support, training case finding and treatment outcomes ~10 million ~10 million 0 Sri Lanka: WB, WHO and GFATM Technical support, drugs, supplies and equipment - Donor coordination and resource mobilization
Major technical partners and type of support provided
Current major Estimated* financial needs financial partners year 2003 and type of activities supported needs available gap
Low/ intermediate burden countries
DPR Korea Sri Lanka
Bhutan
DOTS coverage < 90% - Expanding/improving - 5 year plans: DOTS implementation Plans/Draft plans particularly in remote available. and/or border areas - Global targets by: 2003. - Strengthening recording, reporting, monitoring DOTS coverage and supervision >90% - 5 year plan - Enhancing social available. mobilization and - Global targets community participation by 2003. in TB control
Maldives Nepal
- 5 year plans available. - Global targets achieved.
* including expected additional funding