SECTION IV Detailed information on Tuberculosis [Goal 2] Component of the proposal

SECTION IV – Scope of proposal

23. Identify the component that is detailed in this section (mark with X): Table IV.23 Component HIV/AIDS (Mark with X): X Tuberculosis Malaria HIV/TB

24. Provide a brief summary of the component (Specify the rationale, goal, objectives, activities, expected results, how these activities will be implemented and partners involved) (2–3 paragraphs):

24.1 Specify the rationale for the goal, objectives and activities

The goal of this component is to reduce transmission, morbidity and mortality levels of tuberculosis in Namibia to below that of a public health problem.

The tuberculosis epidemic in Namibia is a major public health problem, which was only well documented after the establishment of a national TB control programme in 1991 and the countrywide implementation of the DOTS strategy 1996. During 1996-2001 tuberculosis notifications increased at 9% annually for new SM+ patients and 6% for all forms of tuberculosis. In 2001 12,935 patients were notified, corresponding to a notification rate of 230/100,000 for new smear positive (SM+) patients and 680/100,000 for all forms of tuberculosis. The increase of tuberculosis is largely attributed to the TB/HIV epidemic, resulting in 45% of TB patients being HIV positive (1998 SSS). TB is also the major cause of death in People Living with HIV/AIDS (PLWHA). Thus the TB programme includes HIV/AIDS care and support activities and the HIV/AIDS programme includes TB diagnosis and treatment (curative and preventive) as part of its care and support activities. In practice Namibia already piloted integrated implementation of joint TB/HIV activities in its hospitals, clinics, and in the community. Objectives and activities regarding joint TB/HIV activities are reflected and described in the case management HIV/AIDS component of this CCP.

While the NTCP (National Tuberculosis Control Programme) is performing well in terms of case-detection under DOTS (WHO Global Tuberculosis Report 2000, 100%), the central problem is that the cure /success rate is poor. Over the cohort years 1996-2000 the cure rate of new SM+ patients averaged 47% and treatment completion rate 19% (success rate 66%). The high default rate (18% for period 1996-2000) is the main reason for the low success rate and is a proxy indicator for poor access to and/or performance of the currently essential health service based DOTS services. The low proportion of patients on DOTS during the full treatment course and the provision of single formulation TB drugs both contribute to the emergence of a non-documented MDR-TB epidemic. Second-line tuberculosis treatment is provided to all patients with MDR-TB, but the effectiveness of this intervention is not routinely monitored, and no data are currently available.

Section IV TB – Page 1 The justification for this proposal is based on the following qualitative sources:

(a) The performance analysis based on the data collected through the routine TB Health Information System 1996-2001. (b) MOHSS 2002 Strategic paper on the National TB Control Programme. (c) The gap analysis and priority-setting exercise conducted as part of Namibia’s preparation for the Global Fund application, by the MOHSS and stakeholders during a workshop on 6 August 2002. (d) Recommendations of the TB Programme Review conducted in 2000.

This proposal aims to address the central inadequacies in the current approach and to expand Community-Based DOTS to all regions of the nation, involving multi-sectoral stakeholders especially NAMTA, Philippi Namibia, Lironga Eparu and the private sector. The involvement of these stakeholders will strengthen and scale up community based DOTS and IEC. The gradual replacement of single drug formulations by 4- and 2-FDCs (Fixed dosage combination drugs) will improve treatment adherence and consequently prevent the rise of MDR-TB. The burden of MDR-TB will be assessed in a national survey while another study will be conducted to assess the current practice of second-line TB treatment and its effectiveness. Under funding and understaffing of the TB programme activities, has caused insufficient and inadequate supervision, at all levels. The absence of: a comprehensive IEC strategy on TB and TB/HIV; a comprehensive pre- and in-service training programme of clinical TB and programme management; operational research capacity; regular surveillance of TB resistance and TB/HIV co-infection in TB patients, are the main constraint areas requiring improvement and are addressed by this proposal. Further, there is focus on strengthening TB management at all levels of the health system through increased human resource capacity development, expected to result in improved TB planning, supervision, coordination and implementation.

24.2 Expected results, implementation of activities and partners involved

Expected results are expressed in terms of an indicator or indicators for each specific sub activity identified by the implementing partner to achieve a main activity of the objective selected. Process/outcome indicators, targets, and partners involved are fully set out in Table IV.27.1

A brief introduction to each implementing partner, an executive summary of their proposal, detailed budget and a working plan when required to further clarify the detailed budget, is attached as Annexure E.

25. Indicate the estimated duration of the component: Table IV.25 From (month/year): 2003 Jan (base year) To (month/year): 2007 Dec

26. Detailed description of the component for its FULL LIFE-CYCLE:

Implementation The NTCP is implemented in the public health sector in all existing health facilities where the core business of TB control, early diagnosis and short-course treatment, if offered free-of- charge to those who need it. NGO hospitals are part and parcel of the TB control network and implement the national TB control policy. The private-for-profit health sector usually refers diagnosed TB patients to the public sector for the actual treatment. The current NTCP DOTS strategy has operational problems resulting in high defaulter rates, low treatment success rates and the emergence of an undocumented MDR-TB epidemic. This is attributed to poor geographical access to TB treatment services resulting in too many patients being treated without DOTS in the continuation phase treatment. In addition the health system is not able to trace patients who do not report for collection of their TB drugs. Frequent rotation of nurses in TB clinics undermines ongoing efforts for improving services to TB patients at clinics. Coordination and supervision of TB control activities at all levels is

Section IV TB – Page 2 inadequate due to competing priorities, participation in clinical duties of district coordinators (nurses), lack of transport. This proposal will strengthen the TB management system at all levels. Staff at national level will be increased; staff at regional level will receive improved training in TB management and staff establishment for the management of TB HIV/AIDS and STI at regional level will be reviewed and adjusted as required; measures will be taken at district level to ensure full-time availability of TB coordinators and ensure high-quality supervision of TB clinics. TB clinics will be reorganised to provide more attractive services to TB patients, and stop frequent rotation of nurses responsible for management of the TB clinic. Strengthening the health system for TB control will provide the basis for introduction and expansion of community-based DOTS, supported and supervised by an effective health system based TB programme. The NTCP at regional and district level will work closely with Community-based organizations, and train trainers in community-based DOTS. The CB-DOTS services will thus become an extension of an optimal functioning health service, not a replacement of an ineffective health system based DOTS programme, as we believe that this will not solve the current problems in NTCP performance.

The introduction of 4- and 2 Fixed Dosage Combinations (FDCs) will improve adherence and thus prevent the emergence of MDR-TB. These drugs will be procured through the national drug procurement system, after an initial procurement from the Global Drug Facility (WHO). Joint TB/HIV interventions in VCT centres, HIV/AIDS clinics, TB clinics and the community at large [early TB case finding through symptomatic screening, promotion of VCT for all TB patients, IPT for HIV+ persons without active TB, IPT for contacts of (HIV+) smear-positive TB patients, CPT, and HAART] are implemented through a coordinated approach at all levels, based on strengthening of both the NTCP and the HIV/AIDS/STI in their core business of disease control. The appointment of additional and special staff responsible for TB/HIV joint interventions at different levels is one of the possible solutions for ensuring optimal and synergistic collaboration in policy development, planning, implementation, supervision, and monitoring and evaluation. Expansion of microscopy services by 50 microscopic centres within the MOHSS hospitals and health centres will ensure that access to TB microscopy is improved beyond the current XX microscopy centres. Turn-around-time of TB microscopy will diminish and clinicians will be better able to utilize TB microscopy as the principal diagnostic tool. Monitoring of progress of individual TB patients will improve, resulting in higher cure rates and lower treatment completion rates. General health workers (mostly nurses) will be trained in sputum microscopy, and a routine supervision and quality control system will be introduced for ensuring high quality sputum smear examination services. Clinical TB referral services will be strengthened at the National TB Referral hospital, providing a training ground for clinicians and nurses in the country (including expatriates) on national TB control policy and management of complicated forms of tuberculosis. Training, IEC, advocacy and operational research capacity will be strengthened through partnerships with existing institutes, in close collaboration with the HIV/AIDS programme where appropriate. Consultants for IEC and other areas will be recruited as necessary, to provide technical advice when this is unavailable in country.

Royal Netherlands Tuberculosis Association (KNCV) and WHO will provide technical assistance in broad TB programme management issues, and more specifically in surveillance of MDR-TB and TB/HIV, TB/HIV, training, technical policies, operational research, writing of a long-term National TB Development and Implementation Plan, and any other important area.

26.1 Goal and expected impact

Goal: to reduce transmission, morbidity and mortality levels of tuberculosis to below that of a public health problem.

The goal is to reduce transmission, morbidity and mortality levels of tuberculosis to below that of a public health problem. IEC interventions will increase the general public’s awareness of the signs and symptoms of TB and this will lead to earlier detection and diagnosis and will ensure that all TB patients are treated, and TB transmission is reduced. Improved patient and family knowledge on the need for continuous treatment for a long period, together with

Section IV TB – Page 3 improved monitoring and the use of DOTS wherever possible and closer to home, will improve cure and treatment success rates and reduce mortality.

People living with HIV/AIDS (PLWHAs) will be given special attention as part of the integrated TB/HIV care delivery system to ensure a continuum of care. Interventions under the other HIV/AIDS component and support groups of PLWHA (Lironga Eparu) and other related projects dealing with HIV-infected persons such as Namibia AIDS Care Trust and Catholic Aids Action will be used as entry points to expand community-based DOTS. Other high-risk groups including farm-workers, San and Ovahimba nomadic people, and migrant workers (including fishery industry and mining), will benefit from specially designed programmes to ensure high treatment success rate through DOTS and early diagnosis through IEC and improved access to TB microscopy diagnosis.

The NTCP will be strengthened to enable it to improve the planning, management, operational research and monitoring of this major public health risk, Table IV.26.1 Goa TO REDUCE TRANSMISSION, MORBIDITY AND MORTALITY LEVELS OF l: TUBERCULOSIS TO BELOW THAT OF A PUBLIC HEALTH PROBLEM.

Impact indicators Baseline Target (last year of proposal) (refer to Annex II) Year: 2002 Year 2007

Incidence (based on notification 680 Less than 350 rate per 100 000)

Tuberculosis mortality rate (per 150 Less than 75 100,000)

27 Objectives and expected outcomes (Describe the specific objectives and expected outcomes that will contribute to realizing the stated goal), (1 paragraph per specific objective):

There are 5 objectives in the Tuberculosis component of this proposal:

1 To improve national treatment success (cure + completion) rate from 64% to 85% by 2007.

2 To strengthen community awareness and action through increased availability of Tuberculosis IEC materials in all 34 districts by 2007.

3 To monitor TB drug resistance, TB/HIV co-infection, and initiate other operational research activities in identified key programme areas from 2003 and onwards.

4 To introduce community-based DOTS to all Regions by 2007.

5 To strengthen overall management capacity of the NTCP by 2007.

Question 27 (objective and expected outcomes) and 27.1 (Broad activities related to each specific objective and expected output) have therefore been repeated five times.

Section IV TB – Page 4 TB Objective 1:To improve national treatment success (cure + completion) rate from 64% to 85% by 2007.

This objective tackles an important weakness in the performance of the programme. At present, confirmation of TB diagnosis as well as monitoring of treatment progress at 2 and 5 months in Namibia is severely hampered by the long distances sputum specimens must travel to be tested at the 26 laboratories, which serve 319 facilities. All 13 regions will be considered for additional microscopy services, which will result in an increased coverage of sputum testing. Bringing diagnostic services closer to home will make it more likely that TB will be diagnosed early and commencement of treatment and follow-up are better implemented. The second strategy focuses on the need to reduce the defaulter rate, currently at 17% average and as much as 32% in one region. Objective 4 will specifically address the strategy of expanding access to Community-Based DOTS, as a major intervention to reduce default rate, and will thus contribute to the achievement of this objective 1. Under this objective the introduction of 4- and 2- Fixed Dose Combinations (FDCs) for the initial and continuation phases of treatment is another important intervention to increase adherence and prevent emergence of MDR-TB. The strengthening of the National Tuberculosis Referral Hospital will serve to improve clinical management of complications of TB and TB/HIV, through training and support of clinicians and nurses.

An intensive advocacy campaign will be implemented directed at all levels of administration and civil society to achieve that receives TB control receives adequate resources. Advocacy will be strengthened for TB through the promotion of TB control in the multi-sectoral response to AIDS, as the primary medical intervention for PLWHA.

Table IV.27 Objective: TB Objective 1: To improve national treatment success (cure + completion) rate from 64% to 85% by 2007. Outcome/coverage indicators Baseli Targets ne (Refer to Annex II) Year Year Year Year Year 1: 2: 3: 4: 5: Treatment success rate 64% 70% 75% 80% 85%

Section IV TB – Page 5 Broad Activities and Expected Output for Objective 1

2.1.1 Improved access to microscopic services in the rural areas

Increased access to microscopic services in the rural areas will be achieved through the creation of 50 additional microscopy centres. 50 microscopes for use in 50 health centres and hospitals will be purchased. This increases capacity for monitoring of treatment progress and will thereby increase the cure rate. 100 candidates from hospitals and health centres will be trained in AFB microscopy. Health workers, in particular nurses, will be considered fro training in AFB microscopy to serve their health centres, while in district hospitals multi purpose laboratory assistants will be trained in AFB microscopy.

2.1.2 Improve adherence to TB treatment using Fixed Dosage Combination drugs (FDC)

It is expected that patient adherence to treatment will be increased by introducing 4- and 2- FDCs for initial and continuation phase of treatment respectively. The introduction of FDCs will require procurement of quality controlled 4- and 2- FDCs and the training of doctors and nurses in their use, in collaboration with the pharmaceutical services division in the MOHSS. Specific IEC materials will be developed and distributed to all health facilities for easy reference by health workers and patients.

2.1.3 Strengthen case management of complicated TB (e.g. MDR TB, Bone TB etc) at National TB Referral Hospital

The human resource capacity of the national TB Referral Hospital will be reviewed with the view to strengthening its expertise and training capacity. Two national medical officers will be sent for specialized TB training abroad (RSA, or other), particularly in complications of tuberculosis, such as MDR-TB, Bone TB, TB/HIV and side effects. A TB documentation and audio-visual centre will be established to enhance the hospital’s training capacity. Training modules on TB will be developed to enable continuous training programmes for different cadres of health workers to be conducted.

2.1.4 Design and implement awareness and advocacy initiatives

The MoHSS will design and implement a joint TB and HIV/AIDS advocacy strategy at all levels of administration. The strategy will provide the framework for ministry, NGO and CBO co- operation to produce advocacy programmes, which address TB as a growing public health problem. People with TB suffer rejection and health workers often dismiss it as a low status disease requiring less attention. The MoHSS will establish TB representation on all its relevant working groups on HIV/AIDS and will develop key messages on TB to be disseminated. The Namibia Tuberculosis Association will use the media and member organizations to make TB more visible and acceptable.

Section IV TB – Page 6 Expected Output for Objective 1 Table IV.27.1 Objective: 2.1 TB Objective 1: To improve national treatment success (cure + completion) rate from 64% to 85% by 2007. Process/Output Indicators Baseline Targets Responsible/Implementing Broad activities (indicate one per activity) Refer Year 2 Year3 Agency or agencies to Annex II) 2.1.1 Improve access to microscopic MOHSS TB Unit – proposal 46a services in the rural areas Target area: all 13 regions Target pop: TB suspects and TB (a) Purchase microscopes for use in # Microscopes purchased 0 20 10 patients on treatment will be the rural areas main beneficiaries from this (b) Provide training in microscopy # Candidates trained 0 40 20 activity. Secondary beneficiaries will include close contacts of smear (+) TB patients who are symptomatic. MOHSS and NIP will implement the activity 2.1.2 Improve adherence to TB MOHSS TB Unit – proposal 46a treatment using FDCs Target area: Baseline year: FDCs procured. Year 2: Erongo, (a) Procure appropriate FDCs % TB patients on FDCs 0 41% 71% Khomas, Ohangwena, Oshana (b) Train HWs (including doctors) in the Year 3: Oshikoto, Okavango, use of FDCs in collaboration with # regions in which HWs have 0 4 8 Kunene, Otjozondjupa the pharmaceutical companies been trained Year 4: Karas, Hardap Omaheke Year 5: Omusati, Caprivi Target pop: All TB patients on treatment 2.1.3 Strengthen case management MoHSS TB Unit – proposal 46a of complicated TB (e.g. MDR Target area: National TB Referral TB, Bone TB etc) at National TB Hospital, Windhoek Referral Hospital Target pop: Tuberculosis patients with clinical (a) Contract a training consultant in # training modules developed 2 complications developing training modules for Implementer: Katutura National different levels of health workers # health workers trained 0 25 25 Hospital, UNAM. passing through the National TB Hospital for orientation (b) Train medical officers in clinical # medical officers trained 0 20 20 management of tuberculosis

Section IV TB – Page 7 2.1.4 Provide counselling & # People trained 0 Philippi Namibia in association psychosocial support training to with University of Namibia VCT staff, peer counsellors and (UNAM) – proposal 11a TB health workers to assist TB Target area: Erongo, patients’ complete treatment in Otjozondjupa, Karas and high priority areas/regions. Khomas regions Target population: Faith-based organizations, NGOs, private sector, orphans, PLWHA groups, youth groups, health workers, counsellors and community groups

Section IV TB – Page 8 TB Objective 2: To strengthen community awareness and action through increased availability of Tuberculosis IEC materials in all 34 districts by 2007.

Given the high prevalence of TB and HIV/AIDS, a large proportion of the adult population is dually infected with TB/HIV (estimated to be 240,000 persons). This objective therefore addresses IEC needs related to both diseases. The activities support community initiatives in raising awareness and increasing community involvement in TB detection, community-based DOTS, and counselling support. A national IEC strategy for TB and TB/HIV will be developed and implemented which encourages community groups to play a crucial role in the dissemination of TB/HIV information about the signs and symptoms of TB, the treatment options, and the need to adhere to treatment. NGOs and support groups of PLWHA will be used as entry points in delivering IEC messages to PLWHA and TB patients, and as vehicles to expand community based DOTS especially to those who are HIV (+) with TB. Carefully planned and pre-tested IEC materials on TB and HIV/TB will be developed and disseminated through NGO networks. Advocacy will be strengthened for TB through the promotion of TB control as the primary medical intervention for PLWHA in the multi-sectoral response to HIV/AIDS. The Namibia Tuberculosis Association will establish public awareness and educational programmes on TB and facilitate awareness-raising campaigns with member organisations. Lay counsellors will be trained, such as VCT staff, peer counsellors, community groups and family members to help TB patients complete their treatment.

The entire initiative will be undertaken in close co-operation with the MIB Take Control Campaign (which will now be extended to include TB and Malaria), in order to make use of existing co-ordinating mechanisms at regional and local level.

Table IV.27 Objective: TB Objective 2: To strengthen community awareness and action through increased availability of Tuberculosis IEC materials in all 34 districts by 2007. Outcome/coverage indicators Baseli Targets ne (Refer to Annex II) Year 1: Year Year Year Year 2: 3: 4: 5: # of districts with available TB IEC 0 10 20 30 34 material

Section IV TB – Page 9 Broad Activities and Expected Output for Objective 2

2.2.1 Develop an appropriate national IEC strategy for TB and TB/HIV to improve health seeking behaviour, enhance early reporting and detection, reduce defaulting and increase cure/completion rate.

A long-term IEC strategy and work plan on TB and TB/HIV will be developed after conducting a needs assessment to identify needs and gaps. The NTCP plans to establish an IEC working group, including HIV/AIDS expertise, to design and conduct an IEC KAP study with focus on TB in the community, TB patients, TB/HIV, and PLWHA. Amongst others, issues such as stigma and discrimination attached to TB and HIV/AIDS, and ways of improving community involvement in the early detection and treatment, will feature in the KAP study and needs assessment. This information will provide a firm basis for developing an appropriate IEC strategy.

2.2.2 Develop and disseminate IEC materials

Building on the findings of the needs assessment and KAP study, and a review of existing TB IEC materials, IEC materials and audio/visual aids will be developed, pre-tested and adjusted as required. IEC materials will be disseminated and, where necessary, health staff will be trained in their appropriate use and application. Community groups, such as support groups for PLWHA, will be encouraged as intermediaries in delivering IEC messages to PLWHA and TB patients.

Section IV TB – Page 10 Broad Activities and Expected Output for Objective 2 Table IV.27.1 TB Objective 2: To strengthen community awareness and action through increased availability of Tuberculosis IEC Objective: materials in all 34 districts by 2007. Process/Output Indicators Baseline Targets Responsible/Implementing (indicate one per activity) Agency or agencies Broad activities Refer to Annex II) Year 2 Year3

2.2.1 Develop an appropriate KAP study report available MoHSS TB Unit – proposal 46a national IEC strategy for TB Target area: national and TB/HIV to improve health Target population: national seeking behaviour, enhance MoHSS, HIV/AIDS media task force, early reporting and detection, consultant, HIV/AIDS NGOs, NAMTA reduce defaulting, increase MoHSS, HIV/AIDS media task force, cure/completion rate. consultant, HIV/AIDS NGOs, NAMTA (a) Conduct a baseline KAP study X with focus on TB in the community, TB patients, TB/HIV, and PLWHA to establish IEC needs (b) Formulate long-term IEC X strategy 2.2.2 Develop and disseminate IEC MoHSS TB Unit – proposal 46a material Target area: national (a) Review, develop, pre-test & # information packages Done Target population: national finalize IEC materials produced MoHSS, HIV/AIDS media task force, (b) Distribute IEC materials and # information packages Done consultant, HIV/AIDS NGOs, NAMTA educate health staff in the distributed MoHSS, HIV/AIDS media task force, HIV/AIDS appropriate use and application NGOs, NAMTA of IEC materials MoHSS, HIV/AIDS media task force, HIV/AIDS NGOs, NAMTA 2.2.3 Design and implement (a) Namibia TB Association – proposal 40a awareness and advocacy Target area: Khomas region (Windhoek and initiatives surrounding areas); Erongo region (Walvis (a) Hold workshop to develop # Of workshops held 1 Bay, Swakopmund and surrounding areas); advocacy strategy Hardap region (Mariental, Maltahöhe, Gibeon (b) Conduct awareness raising # Of campaigns held 5 5 5 and surrounding areas); Karas region campaigns (Keetmanshoop, Lüderitz and surrounding (c) Place articles in media # of articles placed 1/week 1/month 1/month areas).

Section IV TB – Page 11 (d) Organize advocacy sessions # Advocacy sessions held 0 2 2 Target population: Direct: NGOs and CBOs with high-ranking politicians, especially the Shack Dwellers Federation of donors, representatives of civil Namibia, Women Action for Development and society (employer associations, the Workers Unions. NGO’s, NAMTA etc.) Indirect: Communities served by the direct beneficiaries. (b) MOHSS TB unit – proposal 46a Target Population: Politicians, policy makers and influential members of civil society. Target area: national NAMTA (proposal 40A), MoHSS (proposal 46a) NAMTA (proposal 40A), MoHSS (proposal 46a) NAMTA (proposal 40A), MoHSS (proposal 46a) MoHSS TB Unit – proposal 46a Target pop: Politicians, policy makers, and influential members of civil society Target area: national

Section IV TB – Page 12 TB Objective 3: To monitor TB drug resistance, TB/HIV co-infection, and initiate other operational research activities in identified key programme areas from 2003 onwards.

Of major concern to the Ministry is the growing number of MDR-TB cases in Namibia. A national MDR-TB survey is conducted to collect accurate information on the magnitude of resistance to first and second line TB drugs. Research of TB patients with MDR and receiving second-line treatment will aim at understanding non-medical factors associated with MDR TB and the effectiveness of current second-line treatment practices. A TB/HIV co-infection sentinel survey will be conducted every 3 years. The results will be fed into the reviews of both the IEC and advocacy strategies and into programme implementation as a whole.

Table IV.27 Objective: TB Objective 3: To monitor TB drug resistance, TB-HIV co-infection, and initiate other operational research activities in identified key programme areas from 2003 onwards. Outcome/coverage Baseline Targets indicators (Refer to Annex II) Year: Year 2: Year 3: Year Year 5: 4: # Of studies in key 1 2 3 4 programme areas (Second Line (TB/HIV co- (TB drug (TB/HIV completed (cumulative) treatment infection resistance co-infection study) study) study) study)

Broad Activities and Expected Output for Objective 3

2.3.1 Conduct HIV Sero prevalence survey in TB patients every 3 years

The target population is TB patients starting during the time of the survey, using the anonymous unlinked testing method as promoted by WHO and UNAIDS. This will provide precise information on the extent and trend of the TB/HIV dual epidemic.

2.3.2 Monitor TB drug resistance

This component will initiate an MDR-TB survey, to be conducted every 5 years. For the first survey, external expertise will be sought from the Medical Research Council in South Africa and the WHO Global MDR-TB surveillance project, which will also increase the capacity of national TB staff.

2.3.3 Conduct Second Line Treatment Performance Study

The study will be designed to provide an in-depth analysis of MDR TB patients on second-line treatment, focusing on causes of MDR, adherence to treatment guidelines, treatment outcome, with the view to recommending remedial action where required in order to prevent the emergence of resistance against second-line TB drugs.

Section IV TB – Page 13 Broad Activities and Expected Output for Objective 3 Table IV.27.1 TB Objective 3: To monitor TB drug resistance, TB-HIV co-infection, and initiate other operational research activities in Objective: identified key programme areas from 2003 and onwards. Process/Output Indicators (indicate one Baseline Targets Responsible/Implementing per activity) Refer to Annex II) Agency or agencies Broad activities Year 2 Year3

2.3.1 Conduct HIV Sero Survey conducted and report available No Yes - MOHSS TB Unit – proposal 46a prevalence survey in TB Target area: ANC surveillance patients every 3 years areas in all 13 regions Target pop: TB patients on treatment during the time of the surveys 2.3.2 Monitor TB drug Survey conducted and report available No - Yes MOHSS TB Unit – proposal 46a resistance Target area: all 13 regions Target pop: TB patients MOHSS, NIP, MRC, WHO 2.3.3 Conduct Second Line Study conducted and report available Yes - - MOHSS TB Unit – proposal 46a Treatment Performance Target area: all 13 regions Study Target pop: TB patients MOHSS, NIP, SIAPAC, NEDiCO, UNAM

Section IV TB – Page 14 TB Objective 4:To introduce community-based DOTS in all Regions by 2007.

Community-based Directly Observed Treatment (DOTS) remains the cornerstone to reducing the defaulter rate, ensuring adherence, and increasing the cure- and treatment success rate in Namibia to 85% (See also Objective 1). Although DOTS strategy coverage has achieved 100% since 1996 using a 6 months regimen (2RHZE/4HR), access to DOTS is sub-optimal due to the vastness of the country and constraints in geographical accessibility. It is estimated that 20% of TB patients are on self-administered treatment (SAT) during the initial phase. Most TB patients are admitted in hospital for hospital-based DOTS during the initial phase of treatment, but shift to self-administered treatment during the continuation phase. A community-centred approach will be used to ensure decentralised DOTS at the community level increasing both cure and treatment completion rates, supervised by the present TB health services. All diagnosed TB patients and those co-infected with TB/HIV will be targeted for improved access to TB care using community-based DOTS wherever possible and appropriate. A strategy to increase access to community based DOTS will be developed and implemented which will prioritise regions and areas with high defaulter rates. The MoHSS will co-ordinate the training, support and supervision of community-based DOTS supervisors with other partners working in the target areas.

Table IV.27 Objective: TB Objective 4: To introduce community-based DOTS to all Regions by 2007. Outcome/coverage indicators Baseli Targets ne (Refer to Annex II) Year Year Year Year Year 1: 2: 3: 4: 5: # Of regions covered by 2 5 8 11 13 community-based DOTS

Broad Activities and Expected Output for Objective 4

2.4.1 Identify areas with poor access to DOTS and high defaulter rate

Regions with highest default rates are targeted for priority introduction and expansion of Community-Based DOTS. Phasing of the programme will therefore follow this proposed sequence: Oshikoto (32%), Caprivi (no data forthcoming, but highest HIV/AIDS affected region), Khomas (29%), Omaheke (24%), Hardap (19%), Oshana (16%), Kunene (16% DF), Kavango (14% DF), Otjozondjupa (13%), Karas (10%), Omusati (9%), Erongo (8%), Ohangwena (6%).

2.4.2 Develop a strategy to increase access to community based DOTS in order to decrease the defaulter rate.

In collaboration with partners and TB health workers, the NTCP will develop a strategy to increase access to community based DOTS. Experience gained from the OHEP programme in Omaheke Region will be used as a valuable resource for the strategy.

2.4.3 Identify, train and support community-based providers and supervisors for DOTS

Local leaders, CBOs and community members in targeted areas will be sensitised and mobilized to identify potential DOTS providers. The MoHSS will develop and print training manuals for community based DOTS providers in different languages and will train trainers at district and regional level to take responsibility for training and supervision of these DOTS providers.

Section IV TB – Page 15 2.4.4 Involve NGOs/CBOs and other stakeholders to scale up community-based DOTS coverage in all regions

This activity will implement the strategy developed under 2.4.2. NAMTA will expand its human resource capacity to be able to carry out community mobilisation, training and support of community DOTS providers. It will organise exchange visits and hold best practice workshops to share experiences on the implementation of DOTS. Support groups of PLWHA will be encouraged to train DOTS providers, promote the use of DOTS and monitor and sensitively engage in giving TB treatment (DOTS) among people living with HIV/AIDS

Section IV TB – Page 16 Broad Activities and Expected Output for Objective 4 Table IV.27.1 2.4 TB Objective 4: To introduce community-based DOTS to all Regions by 2007 Objective: Process/Output Indicators (indicate one per Baseline Targets Responsible/Implementing activity) Refer to Annex II) Agency or agencies Broad activities Year 2 Year3

2.4.1 Conduct base line # Of areas identified through baseline survey Done MOHSS TB Unit – proposal survey to identify 46a. areas with poor Target pop. All diagnosed TB access to DOTS and patients and those co-infected underlying reasons for with TB/HIV. defaulting

2.4.2 Develop a strategy to Availability of a Community-Based DOTS strategy Done increase access to community based DOTS in order to decrease the defaulter rate. 2.4.3 Identify, train and # community-based DOTS providers trained 0 40 40 MOHSS TB Unit – proposal support community- 46a 0 based DOTS # community-based DOTS providers 200 400 Target pop. All diagnosed TB supervisors and DOTS patients and those co-infected providers # training manuals developed for community based 0 1800 with TB/HIV 2500 DOTS supervisors in different languages 2.4.4 Involve NGOs/CBOs # capacity-building partnership agreements 3 3 (a) Namibia TB Association – and other reached proposal 40a stakeholders to scale Target population and area: up community-based # TB treatment supporters trained 200 250 Khomas region, (Windhoek DOTS coverage in all and surrounding areas); regions # patients supported by TB supporters 600 1000 Erongo region (Walvis Bay, Swakopmund and # PLWHA s trained to provide DOTS 50 40 surrounding areas), Hardap region, (Mariental, Maltahöhe, Gibeon and surrounding areas); Karas region,

Section IV TB – Page 17 (Keetmanshoop, Lüderitz and surrounding areas)

(b) Lironga Eparu – proposal 42a Target area: nationwide Target population: People Living with HIV/AIDS

Section IV TB – Page 18 TB Objective 5: To strengthen overall management capacity of the NTCP by 2007

Human resources, specialized and experienced in Tuberculosis, are limited in Namibia. Capacity at national level needs to be expanded through the recruitment of competent external staff to fill the gap in the short term whilst the implementation of a detailed assessment and the development of HRD strategy will greatly enhance capacity. This objective aims to strengthen the national, regional and district levels of NTCP resulting in improvements in overall programme management, TB coordination, and improved supervision of TB case management. The NTCP will take responsibility for the implementation of the proposal although most activities will be done in a collaborative fashion with other TB stakeholders and partners from various sectors. The human resource development strategy will also address areas such as clinical management, research, training, and regional, district and community level supervision. All 34 health districts, including all health facilities, are involved in the day-to-day management of tuberculosis. NGOs involved in TB control activities will play an increasingly important role, particularly in case detection, advocacy and supporting community-based DOTS. Increased human, technical and logistical capacity will result from this objective’s activities, thereby improving the managerial, monitoring and coordination capacities at all levels of the programme.

Objective: TB Objective 5: To strengthen overall management of the National TB Control Programme (NTCP) by 2007 Outcome/coverage indicators Baseli Targets ne (Refer to Annex II) Year Year Year Year Year 1: 2: 3: 4: 5: # Of regions with adequate 0 7 13 13 13 capacity to monitor and supervise TB programmes.

Broad Activities and Expected Output for Objective 5

2.5.1 Review and increase NTCP human resource capacity at national level

A national TB control programme HRD strategy will be developed to match this growing public health problem. External technical support to the NTCP at central level will be sought in programme management, planning, monitoring, TB/HIV/AIDS and MDR –TB. This will be provided through a combination of long-term and short-term technical support from KNCV, WHO, CDC and free-lance consultants.

2.5.2 Review and increase capacity at regional level for high quality district supervision and improved TB coordination

The capacity of regions for co-ordinating the programme will be reviewed, with regard to the performance, complexity and burden of the specific disease situation. Integrated training modules will be developed and training conducted. The capacity of the regional coordinator, as part of the regional management teams, will be strengthened to provide regular supervision of district programme staff and monitor the progress towards the programme’s objectives.

2.5.3 Review and increase capacity for district level TB management supervision and improved coordination

Refresher training for District Tuberculosis Coordinators (DTCs), Primary Health Care (PHC) supervisors and principal medical officers will be conducted to strengthen the effectiveness of the district level management teams in tuberculosis control. District management – in particular the DTC - will be expected to conduct at least quarterly TB supervisory visits to all health facilities in the district and assess performance of staff. In addition, they will be

Section IV TB – Page 19 responsible for ensuring that community-based partners are engaged, adequately supported and encouraged in their contribution to the programme.

2.5.4 Strengthen National TB Control planning and performance monitoring

A comprehensive 5-year NTCP Development Plan, including an annual work plan for the first year, will form the basis for planning and monitoring. Annual review, monitoring and planning meetings will be held with all regional TB/HIV/AIDS/STI coordinators, regional management teams and stakeholders such as prisons, the Ministry of Defence, NAMTA and other NGOs. Monitoring and evaluation will be strengthened through regular supervision and support at all levels. In addition the capacity of supervisors is to be improved through training to ensure that supervision and analysis of routine reports improves programme performance. Comprehensive analysis of data collected through the Electronic TB Register (supported by CDC) at district level will improve the monitoring of cure, treatment completion and defaulter rates.

2.5.5 Monitor and evaluate progress related to achievements of the overall TB component

Data for quarterly performance monitoring on TB (in line with WHO and IUATLD Guidelines) will be collected, aggregated and analysed at district, regional, and national level. NGOs and other partners will collect, analyse and report data related to their respective TB activities. Regular multi-partner meetings at regional and national level will be held to enhance mechanisms for feedback and programme adjustment. These meetings will be critical to develop or adjust strategies based on operational research findings, epidemiological data, new technologies or interventions, e.g. in the management of TB/HIV/AIDS (HAART).

Section IV TB – Page 20 Broad Activities and Expected Output for Objective 5 Table IV.27.1 TB Objective 5: To strengthen overall management capacity of the National TB Control Programme (NTCP) by 2007 Objective: Process/Output Indicators Baseline Targets Responsible/Implementing (indicate one per activity) Refer to Agency or agencies Broad activities Annex II) Year 2 Year3

2.5.1 Review and increase NTCP human MOHSS TB Unit – proposal resource capacity at national level 46a (a) Recruit competent and qualified # Of staff recruited 2002: 1 4 4 Target area: national external staff to improve 2003: 3 Target pop: MOHSS and programme performance in e.g. client population clinical management, research, KNCV, WHO, other technical training and regional supervision agencies, and free-lancers. (b) Provide regular ongoing external # Of workdays support provided 54 workdays 54 workdays 54 workdays technical support to NTCP central level in programme management, planning, TB/HIV, MDR –TB, operational research 2.5.2 Review and increase capacity at MoHSS TB Unit – proposal regional level for high quality district 46a supervision and improved TB Target area: all 34 health coordination districts in 13 regions (a) Appointment & train Cumulative # of regions with 6 13 13 MoHSS, RMTs TB/HIV/AIDS/STI coordinators in all trained TB/HIV/AIDS/STI regions coordinators (b) Regional coordinators conduct # of supervisory visits made with 4x34 districts 4x34 districts 4x34 districts MoHSS, RMTs quarterly district supervision visits reports visited visited visited (c) Provide reliable transport for quarterly Cumulative # regions with 1 13 0 0 MoHSS, RMTs supervision by regional coordinators to vehicle districts (d) Provide computers to all Cumulative # regions with 10 0 0 TB/HIV/AIDS/STI coordinators at computer equipment regional level

Section IV TB – Page 21 2.5.3 Review and increase capacity for MoHSS TB Unit – proposal district level TB management 46a supervision and improved coordination Target area: all 34 health (a) Conduct quarterly TB supervisory # of supervisory visits to health 4x34 visits 4x34 visits 4x34 visits districts in 13 regions visits to all health facilities in the facilities by DTCs MoHSS, DCC district MoHSS, DCC (b) Provide reliable transport for quarterly # of vehicles procured for districts 1 4 0 supervision to TB clinic in high burden districts as well as those located > 200km from the regional headquarters 2.5.4 Strengthen NTCP planning and # Of planning meetings held with 1 1 1 MOHSS TB Unit – proposal performance monitoring regional HIV/AIDS/TB coordinators 46a Target area: national # Of performance review meetings 1 1 1 Target pop: MoHSS held Regional TB Management and all relevant stakeholders 2.5.5 Monitor and evaluate progress related # of District quarterly TB 4*34 4*34 4*34 MOHSS TB Unit – proposal to achievements of the overall TB notification and treatment outcome 46a component reports Target pop. All diagnosed TB patients and those co- # of Quarterly DTC stakeholder infected with TB/HIV 24 52 performance review and planning Target area: nationwide meetings in each region 52 Unknown Unknown MDR-TB Level of MDR-TB among new and treated TB patients survey (Target new cases: 0-1%) (Target treated cases: 1-2%)

Section IV TB – Page 22 28 Describe how the component adds to or compliments activities already undertaken by the government, external donors, the private sector or other relevant partners:

In July 2002, the Ministry of Health and Social Services led a multi-sectoral and representative gap analysis and priority-setting process, the purpose of which was to identify programmatic and funding gaps in current health delivery services regarding TB, HIV/AIDS, and Malaria. Based on this exercise, goals together with impact indicator/s, objectives, and main activities for each of the diseases were set. These goals, objectives and main activities form the basis for this proposal. They build on relevant objectives as contained in the HIV/AIDS Medium Term Plan II (1999 – 2004) and the second National Development Plan (2002 – 2007) (NDPII).

Resources requested in this proposal complement ongoing funding initiatives and processes in the relevant sectors and by the respective partners. Current resources comes primarily from government and includes the MoHSS primary health care network, TB drugs, costs of TB diagnosis, hospital beds, staff, etc. WHO provides very limited financial and technical support. Few NGOs work in this sector: the Namibia Tuberculosis Association has been a long-standing partner and works with some other CBOs/NGOs but it is also under-funded and Oxfam Canada is closing its four-year programme in Omaheke Region, OHEP, which had a strong TB component and has made a remarkable contribution towards community Based DOTS. Charity organizations have been involved in the provision of food to TB patients in a few locations as an incentive for adherence to treatment. This component scales up infrastructure (expands access to microscopic services), fills gaps (introduces fixed combination drugs, initiates operational research) and scales up access to community-based DOTS, public health programme human resource development, TB/HIV programme planning, management, coordination and monitoring. Two new potential NGO/CBO partners have come forward during the process of developing this proposal, namely Lironga Eparu and the Philippi Namibia, which will contribute to the scaling up process of the NTCP.

This component complements the section on Care and Support in the HIV/AIDS part of the CCP, where TB prevention and treatment is considered a key intervention for PLWHA. In this section, care and support for HIV+ TB patients is embedded in services and interventions provided for PLWHA and tuberculosis infection or disease. Expansion of VCT services will also benefit TB patients. Preventive treatment of opportunistic infections including Cotrimoxazole Preventive Treatment (CPT) will be made available to HIV+ TB patients following established criteria, through the TB programme and – after treatment completion – the services available for HIV/Aids care. Isoniazide Preventive Treatment (IPT) will be offered to HIV+ clients without active tuberculosis, through the TB programme treatment system. HAART will be offered to eligible HIV+ TB patients (estimated at 25% of HIV+ TB patients) who fulfil the national criteria for starting HAART. The development of IEC for communities, PLWHA and TB patients on TB/HIV is another important strategy to achieve early case detection of TB in PLWHA, high treatment success rate of TB, diminish stigma and discrimination. NTCP and HIV/AIDS/STI programmes will collaborate closely in the design, planning and implementation of TB/HIV joint activities, including the monitoring and evaluation of these. This will be formalized through participation of either programme in relevant technical committees and working groups, e.g. for VCT, Care and Support, IEC/Advocacy for maximum synergy.

29 Briefly describe how the component addresses the following issues (1 paragraph per item):

29.1The involvement of beneficiaries such as PLWHA

A large number of Namibia’s adult population is HIV+ (200,000 people) and about 60% of them are infected with tuberculosis. The number of adults dually infected with TB/HUIV is thus estimated at 120,000. The TB/HIV dually infected population is at a very high annual risk of developing active TB disease (5-10% annually). People living with HIV/AIDS will therefore be given special attention as part of the integrated TB/HIV care delivery system to ensure a

Section IV TB – Page 23 continuum of care for TB/HIV co-infected persons, in order to reduce morbidity and mortality. Support groups of PLWHA (Lironga Eparu) and other related projects dealing with HIV- infected persons such as Namibia AIDS Care Trust and Catholic Aids Action will be used as entry points to expand community based DOTS especially to those who are HIV (+) with TB.

29.2 Community participation:

The community based DOTS will be implemented at the community level with the active participation of Community’s Own Resource Persons (CORPS), CBOs and relatives as the key stakeholders for DOTS activities. Potentially marginalized community groups (urban and rural poor) at high risk for TB will be reached through their representative community organizations and NGOs. Health promoters for a community are identified within that community and trained on DOTS and IEC for TB and TB/HIV.

29.3 Gender equality issues

There is no evidence for inequity or inequality in access to TB diagnosis and treatment for either of the sexes. People affected and infected are given equal opportunities for care and support irrespective of gender by the Namibian Health Care system. But notification data show that males are more at risk for TB than females. This is attributed to the dismal living conditions of many young males, who endeavour to find work as seasonal or migrant workers, characterized by crowding in poorly ventilated quarters, and poor nutrition.

29.4 Social equality issues

The MoHSS ensures that all Namibians have access to TB diagnosis and treatment as a right to health as stipulated in the Namibian Constitution, Vision 2030, NDP2, and MoHSS TB policy. TB sputum smear examination, X-ray, and TB treatment are provided free of charge to all patients. The HIV sentinel survey among TB patients uses the anonymous unlinked testing method to ensure confidentiality. The needs in terms of access to care, education and follow up of minority groups such as the San people have been taken into account through the provision/use of various education methodologies. Minority groups have been categorized as high risk groups warranting special care and consideration during the design and implementation of any intervention. There is increased social stigma attached to TB due to its association with HIV/AIDS, and IEC materials will be designed to address misunderstandings in this regard.

29.5 Human Resources development:

Human resource capacity in Tuberculosis is scarce in the public sector. In order to accelerate the implementation of activities related to TB control in this proposal there is an urgent need to strengthen human resources at all levels. Integrated training modules will be developed for regional co-ordinators to make them more competent for their task. At district level-training activities will be increased for TB coordinators, CBOs, and CORPS. The lead NGO agency NAMTA is expanding its current capacity to respond to the growing TB/HIV co-infection by setting up regional offices in northern and southern Namibia staffed by a secretary, a trainer and a community mobiliser. Increasing emphasis is being placed on partnerships with other NGOs such as the workers’ unions, Women’s’ Action for Development, and the Shack Dwellers Federation of Namibia.

Section IV TB – Page 24 29.6. For components dealing with essential drugs and medicine, describe which products and treatment protocols will be used and how rational use will be ensured (i.e. to maximize adherence and monitor resistance)

Namibia applied last year to the Global Drug Facility but its application is still in the process of being resubmitted. In general, the MoHSS is prepared to cover the costs of all TB drugs including FDCs. However, in the first year, in order to accelerate the TB programme, it is propose that WHO approved FDCs of high quality and low costs be procured, and be financed by the Global Fund in the first year. Thereafter the MOHSS will carry the costs. These FDCs will be introduced on the basis of WHO recommendations on their use (weight bands). National Guidelines on TB management will be adjusted accordingly to accommodate their rational use and introduction.

Section IV TB – Page 25