Strengthening TB Control Activities in Somalia - The Global Fund …docs.theglobalfund.org/program-documents/GF_PD_001_bb... · 2017. 3. 30. · 14 . Contact persons ... World Bank,

For the use of the Global Fund Secretariat: Date Received: ID No:

Strengthening TB Control Activities in Somalia

A five-year proposal submitted to

The Global Fund to fight AIDS, Tuberculosis and Malaria International Conference Center Geneva (CICG)

9—11 Rue de Varember (messanine) CH 1202 Geneva

Switzerland

By The Somalia AID Coordinating Body (SACB) through WHO-Somalia as Principal Recipients

Dated: 30 May 2003

Application Form for Proposals to the Global Fund Page 1 of 36

List of Abbreviations AFP: Acute Flaccid Paralysis AIDS: Acquired Immunodeficiency Syndrome CBO: Community Based Organization CCM: Country Coordinating Mechanism CCM-Italy: Comitato Collaborazione Medica-Italy CFR: Case Fatality Rate CISP: Comitato Internazionale Servizio Volontario COOPI: Cooperazione Internazionale COSV: Comitato Coordinamento Servizio Volontario DOT: Directly Observed Treatment DOTS: Directly Observed Treatment Short-course ECHO: European Commission Humanitarian Office EPI: Expanded Program of Immunization EU: European Union FDC: Fixed Drug Combination GAVI: GDF: Global Drug Facility GDP: Gross Domestic Product GMP: HIV: Human Immunodeficiency Virus HRZE: Isoniazid Rifampicin Pyrazinamide Ethambutol ICRC: International Committee of the Red Cross IDP: Internally Displaced People IEC: Information Education Communication IFRC: International Federation Red Cross IGAD: INGO: International Non Governmental Organization IS: KJRC: Kuwait … LFA: Local Fund Agent MDR: Multi Drug Resistant NGO: Non Governmental Organization NPA: Norwegian People Aid OAV: PHC: Primary Health Care PLWHA: People Living With HIV/AIDS PR: Principal Recipient PTB: Pulmonary Tuberculosis QRMs: Quarterly Review Meetings RH: Rifampicin Isoniazid SACB: Somalia AID Coordinating Body SPV: Supervisory SWISSO: TB: Tuberculosis TBCT: Tuberculosis Coordinating Team TOR: Terms of Reference UNDP: United Nations Development Programme UNHCR: United Nations High Commission on Refugees UNICEF: United Nations Children’s Fund VCT: Voluntary Counseling and Testing WFP: World Food Programme WHO: World Health Organization


SECTION I: Executive summary of Proposal

General information: Table I.a Proposal title (Title should reflect scope of proposal):

Strengthening TB control Activities in Somalia

Country or region covered: Somalia

Name of applicant: Somalia Aid Coordinating Body (SACB) – Health Sector Committee Constituencies represented in CCM 3 Government – Health

ministry 4 UN/Multilateral agency

(write the number of members from each Government – Other

ministries 2 Bilateral agency

Category): 6 NGO/Community-based

organisations Academic/Educational Organisations

Private Sector 1 Religious/Faith groups

People living with HIV/TB/Malaria* 1 Other: International

organization (IFRCS/SRCS)

If the proposal is NOT submitted through a CCM, briefly state why:

The proposal is submitted by the Health Sector Committee of the SACB (Somalia Aid Coordination Body). In the absence of a recognized central government in Somalia, this committee meets most requirements outlined for a CCM, shares the main objectives expected from a CCM and could play this role in a country affected by chronic emergency such as Somalia.

Specify which component(s) this proposal is targeting and the amount requested from the Global Fund**:

Table I.b Amount requested from the GF (USD thousands) Year 1 Year 2 Year 3 Year 4 Year 5 Total

Component HIV/AIDS

X TB 2.857.166 2.234.848 2.439.996 2.463.529 2.572.780

13.825.151

Malaria

HIV/TB

Total 2.857.166 2.234.848 2.439.996 2.463.529 2.572.780 13.825.15

1 Total funds from other sources for activities related to proposal

1,822,566 1,723,502 1,661,000 1,661,000 1,661,000 12,117,794

Please specify how you would like your proposal to be evaluated*** (mark with X): The Proposal should be evaluated as a whole X The Proposal should be evaluated as separate components

* According to national epidemiological profile/characteristics ** If the proposal is fully integrated, whereby one component cannot be separated from another, and where splitting budgets would not be realistic or feasible, only fill the “Total” row. *** This will ensure the proposal is evaluated in the same spirit as it was written. If evaluated as a whole, all components will be considered as parts of an integrated proposal. If evaluated as separate components, each component will be considered as a stand-alone component.


Brief proposal summary (1 page) (please include quantitative information where possible):

• Describe the overall goals, objectives and main activities per component, including expected results and timeframe for achieving these results:

The present proposal aims at decreasing TB incidence and prevent the development of acquired drug resistance. The expected impact is to reverse the present trend and reduce the incidence rate of smear +ve cases by 3% per annum, from 162 per 100,000 in 2002 to 139 per 100,000 in 2008. The main objectives are to increase access to DOTS facilities and to improve quality of care for TB patients, achieving the targets of 70% Case Detection Rate and of 85% Treatment Success Rate by 2007 and maintain the achievements. The expected outcome is the DOTS services available to the whole population of Somalia (6 to 7 million), detecting around 14,000 new TB cases (50% of the estimated total incidence) annually by 2008 and curing an average of 6,250 TB smear +ve patients per year. To reach the set targets, the program will assist the implementing organizations in strengthening the existing services and establishing new peripheral TB centers in areas at present not covered. To improve the quality of treatment, the program will continue to ensure a regular supply of drugs and laboratory supplies to all TB centers, provide training to staff, strengthen supervision, monitoring and evaluation activities. The implementing partners will work in close collaboration with the existing and emerging local health authorities so to facilitate governments’ progressive involvement and ownership of the program.

• Specify the beneficiaries of the proposal per component and the benefits expected to accrue to them (including target populations and their estimated number):

The principal beneficiaries of the proposal are the TB patients that will be treated under DOTS. Throughout the period of the program (2004 – 2008), more than 55,000 TB cases will be detected and treated by the expanded DOTS services, thus saving about 20,000 lives (CFR/5 years = 60% smear +ve, 10% others). Secondary beneficiaries are the patients’ families and the communities where the patients live, who will be at lower risk of acquiring the infection. It is estimated that with the support of the Global Fund 70% of the population (4.6 million) will eventually benefit from the preventive and curative measures adopted to reduce the burden of TB in Somalia. Another relevant group of beneficiaries is represented by the health workers and local authorities who will be trained in TB during the project period.

• If there are several components, describe the synergies, if any, expected from the combination of different components

Not applicable

• Indicate if the proposal is to scale up existing efforts or initiate new activities. Explain

how lessons learned and best practices have been reflected in this proposal and describe innovative aspects to the proposal

The TB control program in Somalia has reached surprisingly good results (80% treatment success rate, 42% case detection rate) notwithstanding the complex emergency situation in which it had to operate. TB control activities have been implemented by several NGOs under the coordination and technical assistance provided by WHO. For the past 8 years, the fundamental elements of the program (provision of high quality drugs, basic training on DOTS, regular monitoring and supervision, surveillance) have been implemented to the best of the partners’ capacities. However, with the available resources, the Somalia TB program has reached or is approaching its maximal expansion capacity. The provision of services to a greater number of people and the achievement of the set targets can be reached only through the expansion of the intake capacity of the existing centers and the opening of new ones, which require additional resources in terms of manpower, infrastructures, equipment and supplies. The proposal therefore aims at filling the gap for DOTS expansion along with the plan agreed upon by all the partners involved in the program.


SECTION II: Information about the applicant

Non-CCM applicant 12. Name of applicant:

Somalia Aid Coordination Body (SACB) – Health Sector Committee

13. Representative of organisation applying:

Table II.13 Representative Alternate Name Mario Maritano Roberto De Bernardi Title Dr. (Chairman SACB/HSC) Dr. (Vice-Chairman SACB/HSC)

Address European Commission Kenya Delegation – Somalia Unit PO Box 30475 Nairobi, Kenya

Health and Nutrition Program Officer, UNICEF Somalia PO Box 44145 Nairobi, Kenya

Telephone +254 20 2714496 – 2712957 +254 20 623862 Fax +254 20 2710997 +254 20 623965 E-mail [email protected] [email protected] 14. Contact persons for questions regarding this proposal (please provide full contact

details for two persons – this is necessary to ensure expedient and responsive communications):

Please note: The persons below need to be readily accessible for technical or administrative clarification purposes by the Secretariat or the TRP members.

Table II.14

Primary contact Secondary contact Name Hashim Suleiman Imanol Berakoetxea

Title Dr. (Communicable Diseases Officer) Dr. (Somalia Health Coordinator for International Organizations)

Address WHO Somalia, PO Box 653 Hargheisa Somaliland

c/o UNDP for Somalia PO Box 61950 Nairobi, Kenya

Telephone +252 8 283030 +254 20 4448434/5/6 Fax +254 2 623200 +254 20 4448439 / 4442438

E-mail [email protected] [email protected] [email protected]

15. Description of applying organisation Established in December 1993, at the 4th Coordination meeting on Humanitarian Assistance for Somalia facilitated by the UN in Addis Ababa, the SACB is a voluntary body, which aims to provide a framework to develop a common approach for the allocation of international aid to Somalia. It comprises some 117 partner agencies, including main Donors (bilateral and multilateral), UN Agencies and international NGOs. The ICRC and the IFRC remain autonomous, but act in close cooperation. Other international and regional bodies such as IGAD, World Bank, the OAU, the Organization of the Islamic Conference and the Arab League maintain ad hoc membership, mainly as observers. In addition there is a network of local Somali organizations, which regularly participate in some SACB meetings.


The SACB mandate:

To provide policy guidance and practical assistance to implementing agencies

on issues of policy, security and operational constraints.

To provide policy and operational coordination for rehabilitation and development activities, particularly at the sector level.

To develop recommendations for the allocation of resources to different regions.

To provide a base for possible resource allocation.

How it works: It operates through a network of committees supported by a Secretariat. There are three main committees: Executive, Steering and Consultative, and five Sectoral committees (Health & Nutrition, Education, Food Security and Rural Development, Water/Sanitation and Infrastructure, Local Administration) Given his voluntary nature the SACB reaches decisions by consensus. All decisions of the SACB and at all levels are therefore issued in the form of recommendations, emphasizing the non-authoritarian nature of the Body. However, in the continued absence of legitimate and internationally recognized forms of governance in Somalia, the SACB became, over time, a reference point, a source of information and advice for the formulation of decisions by external actors in the majority of situations. The final document of the 4th SACB meeting, held in Rome in May 1997, outlines general recommendations within the SACB strategy, amongst them: Adequate funding and a clear understanding with Somali partners for the effective implementation of the international strategy :

“The volatile continuum from relief to rehabilitation and development in Somalia requires long-term political and financial commitment by the donor community. Only adequate funding level can ensure effective international aid involvement and allow the implementation of the strategy of the international community in Somalia”.

“The strategy of the international aid community in Somalia and the conclusions of the 4th SACB meeting in Rome should be communicated to and discussed with the Somali people and their leaders as a fundamental element in a constructive partnership towards peace building, reconstruction and development”.

For additional information see Annex 4.a – 4.e or/and consult the SACB basic informative document available from the SACB Secretariat, or from the Somalia Health Sector Coordination office/SHSC) 15.1 Indicate what type of organisation the applicant is (mark with X):

Table II.15.1

Non-Governmental Organisation (NGO) or network of NGOs Community based Organisation (CBO) or network of CBOs Private Sector Academic/ Educational Sector Faith-based Organisation Regional Organisation

X Other (please specify): Somalia Aid Coordinating Body (SACB) – Health Sectoral Committee


15.2 Provide as attachment the following documentation:

• Statutes of organisation (official registration papers) • A presentation of the organisation, including background and

history, scope of work, past and current activities • Reference letter(s), if available • Main sources of funding

The documents are included as Annexes 4.a to 4.e

16. Justification for applying outside the CCM 16.1 Indicate reasons for not applying through the CCM (Explain clearly the

circumstances, conditions and reasons) (1–2 paragraphs): Due to the absence of a recognized central government in Somalia for the last 12 years after the collapse of the former government (December 1989), basic conditions applying for normal countries where the government plays a major role in establishing and leading a CCM, are still not present in Somalia. As described in detail in the Annexes 4.b, the SACB forum was established in 1993 as a body attempting to provide basic coordinate on structures as well as a vehicle through which international actors and local organizations could interact to better serve the interests of the Somali people. Since May 1995 the Health Sector Committee of the SACB (see TOR in Annexes 4.c) has been trying to offer to all partners (international NGOs, local organizations and emerging local authorities) a forum to ensure proper coordination and to provide technical guidance on priority areas within the health sector addressing emergencies, rehabilitation and developmental activities. The Health Sector Committee of the SACB has been meeting in Nairobi on a monthly basis since then and, despite the difficult operational environment, has been able to play an important coordination role recognized by international actors as well as by local health authorities. An average of 25 international organizations has participated at the monthly meetings since 1995. Recently the Health Sector Committee was recently requested to endorse a joint country proposal to the GAVI fund. The Health Sector Committee accepted this responsibility and ensured that all elements requested for this proposal had been addressed in a fully coordinated, participatory and transparent manner. After verification of all the components of this application by the GAVI technical committee, the proposal was finally accepted. Funds from GAVI are managed by UN agencies (UNICEF/WHO) and the SACB Health Sector Committee provides the required coordination on the implementation and monitoring of the EPI strategy. Since the SACB is a coordination forum and not an organization or institution, it does not have either the legal entity or the financial/managerial capacity to be the principal recipient of the funds requested from the Global Fund. For this reason the Health Sector Committee of the SACB has selected (unanimously) relevant UN Agencies (UNICEF and WHO) to be the recipients of the funds, to be used by implementing partners (NGOs, local authorities) to cover the gaps of the available funding for Somalia. Within this approach the Health Sector Committee of the SACB will remain responsible for ensuring that the funds are allocated in a transparent and accountable manner, to better serve the jointly developed strategies. This should be ensured by


the monthly activities of the respective technical groups (TB, Roll Back Malaria and HIV/AIDS working groups). In order to ensure that the monitoring role is performed according to the requirements of the Global Fund, SACB coordinators for each disease will be appointed to guarantee specific expertise and constant support both at operational and monitoring level. Funds requested from the Global Fund will also be used to allow regular participation of representatives of the emerging local health authorities in the monitoring process. This will offer a good opportunity to increase their capacities at technical and managerial level (contributing to building the sustainability of the intervention in the three areas). N.B.: If required, minutes from the general monthly health meetings and from the relevant working groups are available for verification of the level of coordination and technical discussions held on the process. 16.2 Have you been in contact with the CCM in your country or other

relevant governmental agencies (e.g., Ministry of Health, National AIDS Council)? If so, what was the outcome? If not, why?

The existing health authorities (Ministry of Health and Labor in Somaliland, Ministry of Social Affairs in Puntland, Transitional National Government in Mogadishu) have been informed of the process through official communications (minutes of SACB working group on the Global Fund and official letters from the SACB) and through relevant bilateral discussions. The three ministries of health have been invited to provide their inputs on the proposal. The present political situation in the country (i.e. recent elections in Somaliland, final stages of deliberations to try to agree with a new transitional government as an outcome of the peace and reconciliation process supported by the international community, power sharing negotiations in Puntland) have hampered contacts and proper interaction with the health authorities of the various Zones, during the process of reformulation and submission of the present proposal. Information on the content of the proposal has been shared with the health authorities during the process of redrafting the proposal, but due to the above mentioned constraints, it has not been possible to gather official endorsement within the deadline. The SACB remains committed to engage the existing and emerging Somali health authorities, as a vital stakeholder of the TB control intervention. 16.3 Include letters from supporting organisations (e.g. human rights

groups, NGO networks, bilateral or multilateral organisations, etc) supporting your reasons for not applying through a CCM as attachment.

Letters from all supporting organizations are included in the hardcopy as Annex 6.


SECTION III: General information about the country setting

18. Describe the burden or potential burden of TB: (Describe current epidemiological

data on prevalence, incidence or magnitude of the diseases; its current status or stage of the diseases; major trends of the diseases disaggregated by geographical locations and population groups, where this data is available and/or relevant) (1 – 2 paragraphs per disease covered in proposal):

With one of the highest incidence in the world (372 per 100,000 population), the total number of expected TB cases in Somalia is approximately 25,000 per year. The number of estimated smear positive cases is 11,000 per year (162 per 100,000 population). TB affects mostly people of reproductive age (56% of notified cases belong to the age group 15-34) with men more affected than women (68% of the total of smear positive cases). In Somalia TB is strongly correlated with poor economic conditions: many patients are refugees or returnees from neighboring countries, many others have lived for more than a decade in war zones. Malnutrition is common among TB patients and HIV co-infection is rapidly increasing. From the epidemiological point of view, case detection rate has been improving in the past years and reached 43% in 2001 (around 7,200 TB cases out of which 4,700 smear positive were detected in the 30 facilities that provide TB services around Somalia). Case detection rates are higher in the North West Zone (78%) where there is a large influx of refugees/returnees and where peace has facilitated the development of efficient TB hospitals. Case detection rates are lower in the North East Zone (34%) and in Central and South Somalia (29% and 63% respectively) where instability and limited number of TB hospitals have affected the provision of services to the population. Treatment success rate was 80% in 2000 with no significant regional differences.

19. Describe the current economic and poverty situation (Referring to official indicators such as GNP per capita, Human Development Index (HDI), poverty indices, or other information on resource availability; highlight major trends and implications of the economic situation in the context of the targeted diseases) (1–2 paragraphs): According to UNDP Human Development report 2001, Somalia has a population of approximately 6.38 million and an annual population growth rate of 2.76%†. Over a decade of war has left the country totally devastated in terms of infrastructure, material and human resources. There has been massive displacement of people, shortage of food, destruction of agricultural fields as well as health, educational, social and administrative infrastructures. Apart from the large number of Somali, estimated over one million, fled to developed countries (i.e. EU, Canada, Australia and US), many Somalis remain refugees in neighboring countries (around 246,400) and a larger number are internally displaced (around 300,000). By 1998-99 the average life expectancy was 47 years; maternal mortality rate was 1600/100,000 live births; infant mortality rate was 132/1000 live births; under-five mortality rate 224/1000 live births , an adult literacy rate 17.1%, only 23% of the population has access to clean water and an estimate of 0.4 doctors per 100,000 persons. It is estimated that over 75% of the Somali population live below the poverty line. Approximately 59% of the population practice nomadic, semi-nomadic or agro-pastoralism and rely on livestock (camel, cattle, goat and sheep) for living, 17% of the population practice sedentary agriculture and 24% live in urban settlements. According to the 2001 UNDP Human Development Report, Somalia has a GDP per capita of approximately US$200 and a Human Development Index of 0.284, making it

† UNDP Human Development Report



the third poorest country in the world, following Niger and Sierra Leone. With the above situation, financial remittances from Somalis living abroad are perhaps the main income in the Somali economy. Though reliable data on remittance are hard to obtain, it is estimated to be between US$ 300 – 500 million per year.

20. Describe the current political commitment in responding to the diseases (indicators of political commitment include the existence of inter-sectoral committees, recent public pronouncements, appropriate legislations, etc.) (1–2 paragraphs): As Somalia continues to experience civil war, political stability has not yet been reached in the country. In the central and southern zones of Somalia, a Transitional National Government has been established while in the northwestern zone (Somaliland) and northeastern zone (Puntland) two other governments are in power. While fights erupt in different parts of the country, a reconciliation process is currently undergoing under the auspices of the international community. Previous similar experiences have failed: however, it is widely recognized that the concrete possibility to fully address the health problems in Somalia relies on peace and stability in the country. Notwithstanding these challenges, the political commitment in responding to health issues is growing as indicated by the establishment of Ministries of Health/Social Affairs within the different governments. As the provision of health services is still dependent on external technical and financial support, UN agencies, NGOs and community-based organizations are de facto the implementers of more than 95% of all public health programs. Coordination between health authorities and donor agencies/implementers is guaranteed by the SACB Health Sector Committee through regular meetings and constant sharing of relevant health information.

22. National context

22.1 Indicate the percentage of the total government budget allocated to health (optional for NGO applicants): Ministries responsible for health in the local authorities lack adequate resources for the provision of health services. However, under the SACB’s umbrella the ministries of health are in partnership with UN agencies (UNICEF, WHO, UNDP, UNHCR, WHO, etc) as well as with a large number of international NGOs, local NGOs and community-based organizations that provide funds for public curative services throughout the country. Present levels of resource commitment are hard to estimate and remain largely unknown.

22.2 Indicate national health spending for 2001, or latest year available, in the Table III.22.2 (optional for NGO applicants):

Table III.22.2 Total national health

spending 2002: (USD)

Spending per capita (USD)

(6.5 M people) Public unknown unknown Private unknown unknown Total unknown unknown From total, how much is from external donors? 26,279.477 (a) 4.04

(a) Bilateral and multilateral contribution for the Health and Nutrition Sector in 2002 22.3 Specify in Table III.22.3, if possible, earmarked expenditures for HIV/AIDS,

TB and/or Malaria (expenditures from the health, education, social services and other relevant sectors):

Table III.22.3


Total earmarked expenditures from government, external donors, etc. Specify Year:

In US dollars: 2002

HIV/AIDS - Tuberculosis 1,875,500 Malaria - Total 1,875,500

22.4 Does the country benefit from external budget support, Highly Indebted Poor Countries (HIPC) initiatives, Sector-Wide Approaches? If yes, how are these processes contributing to efforts against HIV/AIDS, TB and/or malaria? (1–2 paragraphs) (optional for NGO applicants):

Somalia does not benefit from initiatives like HIPC or Sector Wide Approaches.

22.5 Describe the current national capacity (state of systems and services) that

exist in response to HIV/AIDS, TB and/or Malaria (e.g., level of human resources available, health and other relevant infrastructure, types of interventions provided, mechanisms to channel funds, existence of social funds, etc.) (2–3 paragraphs):

As specified above, the international community plays a fundamental role in sustaining the weak health infrastructure and the services provided to the Somali people. Health personnel are inadequate in quantity and quality; infrastructures have been damaged by the prolonged civil war and neglected by administrations without funds. Services are provided through international partners and direct involvement of local authorities is still limited. Notwithstanding these obstacles, certain health programs (e.g. TB, polio, etc.) have obtained successful results thanks to effective collaboration among all partners: the network of international NGOs, local NGOs, UN Agencies and local authorities has proven that TB and malaria programs can be effectively implemented even in complex emergencies. At present, strengthening the capacity of the existing network is the only viable alternative in order to reduce the death toll due to malaria and TB in the country. The capacity building of local health personnel linked to the support of existing facilities will eventually contribute to improve the state of systems and services in Somalia.


22.6 Name the main national and international agencies involved in national

responses to HIV/AIDS, TB and/or Malaria and their main programmes (NGO applicants should specify partner organisations):

Table III. 22.6

Name of Agency Type of Agency Main programs Budget

2002

WHO UN Agency

Provision of drugs/lab supplies/register forms to all TB centers, Data collection and analysis, Training activities, Monitoring and supervision

415.500

WFP UN Agency Food for TB patients 770.000 ECHO EU Agency Air carrier 168,000 World Vision Faith based Support to 3 TB Centers 30.000 NPA NGO Support to 3 TB Centers 30.000 A. Tonelli Private Support to TB hospital in Boroma 90.000 CISP NGO (EC) Support to 2 TB Centers 40.000 COOPI NGO (EC) Support to 2 TB Centers 10.500 COSV NGO (EC) Support to 1 TB Hospital 10.000 SWISSO NGO Support to 1 TB Center 60.000 INTERSOS NGO (EC) Support to 1 TB Center 18.360 KJRC NGO Support to 1 TB Hospital 100.000 Erigavo Municipality Local Authorities Support to 1 TB Hospital 16.000

8 other NGOs NGOs Support to 16 TB centers/hospitals all over Somalia Not avail.

TOTAL (US$) 1,758,360

22.7 What is the total budget required for the different diseases, list the sources and amounts available and needed including amount requested from the Global Fund.

Table III. 22.7

Amount In US dollars: Source/ Agency 2002 2003 2004 2005 2006 2007 2008 Tuberculosis WHO 415,500 420,000 420,000 420,000 420,000 420,000 420,000 WFP 770,000 770,000 770,000 770,000 770,000 770,000 770,000 ECHO 168,000 168,000 336,000 336,000 336,000 336,000 336,000 NGOs 404,860 472,366 396,566 197,502 135,000 135,000 135,000 Global Fund request

2.857.166 2.234.848 2.439.996 2.463.529 2.572.780

Unmet need ? ? ? ? ? ? ? Total need ? ? ? ? ? ? ?

22.8 Describe the major programmatic intervention gaps and funding gaps that exist in the country’s current response to TB (2-3 Paragraphs) Most health projects implemented by INGOs and funded by International donors address TB within the wider range of health problems addressed through PHC and hospital services. This is complemented by major programmatic interventions supported by UNICEF and WHO. Available resources in the Somalia TB program are fully spent for sustaining basic activities in the centers so to guarantee that key components of the TB program are effectively in place (e.g. drug provision under DOT, free of charge services, regular laboratory activities etc.). Current investments have led to very positive results in the past


years (80% treatment success rate, 42% case detection rate) through continuous DOTS expansion and effective collaboration among partners. However, with the available resources, the Somalia TB program has reached or is approaching its maximal expansion capacity. The provision of services to a greater number of people and the achievement of the case detection target can be reached only through the expansion of the intake capacity of the existing centers and the opening of new ones (provided that the security situation remains stable or improves), which require additional resources in terms of manpower, infrastructures, equipment and supplies. Moreover, due to the variety of the funding cycles and administrative procedures used by the various donors, at times implementing organizations face funding gaps. Financial support from the Global Fund would play a crucial role in covering (bridging) these periods and ensuring the necessary continuity of the program in these areas.

22.9 If a SWAp or a similar fund pooling mechanism exists in your country, briefly describe how it is functioning and if you anticipate using it to administer the Global Fund grant

No such mechanism is existing.


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): The TB control program in Somalia, since its inception in 1994-5, has steadily improved, reaching surprisingly good results in terms of cure rates, notwithstanding the complex emergency situation in which it had to operate. At present there are 30 operational TB centers, all of them implementing DOTS strategy. In 2002, a Case Detection Rate of 43% and a Treatment Success Rate of 80% (2000) was reached (see Annex 1 for detailed situation analysis and rationale). In recent years, though, the progress has slowed down and further improvements seem difficult unless additional resources are made available. In light of the extremely serious burden of TB (incidence of new smear +ve cases of 162/100,000), the program needs to scale up DOTS activities as quickly as possible. The funds available to partners, though, are only sufficient to maintain the ongoing activities, while they don’t allow the required expansion. This proposal therefore aims at filling the gap for the expansion of DOTS in Somalia. The present proposal aims at decreasing TB incidence and prevent the development of acquired drug resistance. The expected impact is to reverse the present trend and reduce the incidence rate of smear +ve cases by 3% per annum, from 162 per 100,000 population in 2002 to 139 per 100,000 population in 2008. The main objectives of this proposal are to increase access to DOTS facilities and to improve quality of care for TB patients, achieving the targets of 70% Case Detection Rate and of 85% Treatment Success Rate by 2007 and maintain the achievements. The expected outcome is to make the DOTS services available to the whole population of Somalia (6 to 7 million), detecting around 14,000 new TB cases (50% of the estimated total incidence) annually by 2008 and curing an average of 6,250 TB smear +ve patients per year. Throughout the period of the program (2004 – 2008), more than 55,000 TB cases will be detected and treated through the expanded DOTS services, thus saving about 20,000 lives (CFR/5 years = 60% smear +ve, 10% others). To reach the set targets on treatment (85% treatment success rate) and on case detection (70% of the new smear +ve TB cases) by 2007, the program will assist the implementing organizations in strengthening the existing services and establishing new peripheral TB centers in areas at present not covered. At the end of the program, there will be a total of 35 TB centers, which will provide standardized short-course chemotherapy under direct observation to all identified TB cases. To improve the quality of treatment, the program will continue to ensure a regular supply of drugs and laboratory supplies to all TB centers, provide training to staff, strengthen supervision, monitoring and evaluation activities. Somalia remains a country under complex emergency without clear political leadership and with serious problems of access. The main implementers of this proposal are several NGOs and the WHO, all members of the SACB forum. NGOs and WHO will work in close collaboration with the existing and emerging local health authorities so to facilitate the governments’ progressive involvement and ownership of the TB control program. Strengthening the managerial


and technical capacity of local authorities is therefore an important outcome of the component, in order to allow their progressive empowerment. All partners will work closely through the SACB TB Coordinating Team chaired by WHO, who will take the overall coordinating role through its offices in Kenya and Somalia.

25. Indicate the estimated duration of the component:

Table IV.25 From (month/year): January 2004 To (month/year): December 2008 26. Detailed description of the component for its FULL LIFE-CYCLE:

26.1 Goal and expected impact (Describe overall goal of component and what impact, if applicable, is expected on the targeted populations, the burden of disease, etc.) (1–2 paragraphs):

The overall goal of the program is to decrease the mortality and morbidity due to TB in Somalia. The program aims at decreasing TB prevalence and TB transmission, which will result in a reduced TB incidence. At the same time, the development of acquired drug resistance will be prevented thus making future treatment of TB easier and more affordable. The expected impact is to reverse the trend of tuberculosis in Somalia and reduce the incidence rate of smear +ve cases by 3% per annum, from 162 per 100,000 population in 2002 to 139 per 100,000 population in 2008. The achievement of the overall target will be evaluated through a tuberculin survey conducted during the first and last year of the program.

Table IV.26.1

Goal: To reduce mortality and morbidity due to TB and prevent the development of anti-TB drug resistance

Impact indicators Baseline Target (last year of proposal)

Year: 2002

Year: 2008

Incidence of smear +ve cases per 100,000 population 162 139


26.2 Objectives and expected outcomes (Describe the specific objectives and expected outcomes that will contribute to realizing the stated goal):

The objective of the program is to increase the access to DOTS facilities and improve the quality of care for TB patients, achieving the targets of 70% Case Detection Rate and of 85% Treatment Success Rate by 2007 and maintain the achievements. The expected outcome is to make the DOTS services available to the whole population of Somalia (6 - 7 million), detecting around 14,000 new TB cases (50% of the estimated total incidence) annually by 2008 and curing an average of 6,250 TB smear +ve patients per year. Throughout the period of the program (2004 – 2008), more than 55,000 TB cases will be detected and treated by the expanded DOTS services, thus saving about 20,000 lives (CFR/5 years = 60% smear +ve, 10% others).

Table IV.26.2

Objective: Increase the access to DOTS facilities and improve the quality of care

Baseline Targets Outcome/coverage indicators Year:

2002 Year 2:

2005 Year 3:

2006 Year 4:

2007 Year 5: 2008

Number and % of estimated new smear +ve TB cases detected under DOTS (Case Detection Rate) (a)

4,691/ 10,800 43%

6,435/ 11,700 55%

7,800/ 12,000 65%

8,610/ 12,300 70%

8,890/ 12,700 70%

Number and % of estimated total new TB patients detected under DOTS (a)

6,831/ 24,800 28%

9,380/ 26,800 35%

11,040/ 27,600 40%

12,735/ 28,300 45%

14,550/ 29,100 50%

Number and % of TB centers implementing DOTS

30/30 100%

35/35 100%

35/35 100%

35/35 100%

35/35 100%

Number and % of smear +ve cases registered under DOTS successfully treated (b)

2,815/ 3,518 80%

5,277/ 6,435 82%

6,474/ 7,800 83%

7,318/ 8,610 85%

7,556/ 8,890 85%

Number and % of TB cases defaulting (b)

115/ 3,518 3%

257/ 6,435 < 4%

312/ 7,800 < 4%

344/ 8,610 < 4%

355/ 8,890 < 4%

(a) Denominators are rounded to the nearest 00. (b) Figures from the year 2000.


26.3 Broad activities related to each specific objective and expected output (Describe the main activities to be undertaken, such as specific interventions, to achieve the stated objectives) (1 short paragraph per broad activity):

TableIV.26.3

Objective: Increase the access to DOTS facilities and improve the quality of care Baseline Targets Main

activities Process/Output Indicators Year:

2002 Year 1 Year 2

Responsible/ Implementing agency(ies)

Human Resources Number and % of TB centers with adequate staffing - 33/33

100% 35/35 100% Recruit staff Number and proportion of

managerial staff in place - 14/14 100%

14/14 100%

Impl. Orgs WHO Local author. CCM-Italy

Infrastructures and equipment Estab./Exp. TB centers

Number of new TB centers established or expanded - 7/14

50% 14/14 100% Impl. Orgs

Procure equipment

Number and % of TB centers with adequate lab equipment - 33/33

100% 35/35 100%

Impl. Orgs WHO

Training/Planning Number and % of health staff trained in DOTS - 60/120

50% 120/120 100% Conduct

training Number and % of lab techn. trained in microscopy - 35/70

50% 70/70 100%

Impl. Orgs WHO CCM-Italy

Develop Partnership

Number and % of planned activities for coordination actually conducted

- 5/5 100%

4/4 100%

WHO Local author. CCM-Italy

Strengthen local capacity

Number of local staff with managerial responsibilities

0 0%

6/6 100%

6/6 100% Local author.

Conduct IEC activit.

Number and % of patients with basic knowledge on TB - 60% 70% Impl. Orgs

Commodities/Products Procure & distribute lab. supply

Number and % of TB centers with stock-out of laboratory supplies

2/30 6%

0/33 0%

0/35 0%

WHO CCM-Italy

Dev./distr. IEC and IS material

Number and % of TB centers with stock-out of IEC and TB IS materials

- 0/33 0%

0/35 0%

WHO CCM-Italy

Drugs Number and % of TB centers with stock-out of TB drugs

2/30 6%

0/33 0%

0/35 0% Procure &

distribute TB drugs % of drugs having expired in

stock by type - 0% 0% WHO

Supervision and Monitoring

Conduct supervision

Average number and % of SPV visits per TB center

-

4/4 100%

4/4 100%

WHO Local author. CCM-Italy

Microscopy quality control

Proportion of evaluated smears correctly read on standard sample size

-

90%

95%

WHO CCM-Italy

Establish a TB Inf. System

Number and proportion of TB units submitting accurate, complete and timely reports

30/30 100%

33/33 100%

35/35 100%

Impl. Orgs WHO CCM-Italy

Conduct operational researches

Number and % of planned operational researches actually conducted

- 1/1 100%

1/1 100%

Impl. Orgs WHO

Note: missing baseline data will be collected at beginning of implementation


The Guidelines for Tuberculosis Control in Somalia will be used as technical reference (see Annex 3). The Guidelines were developed in 1994 and are currently being revised and updated. The document defines case detection and case definition policies, standardized treatment regimens and information system. To ensure an adequate standard of services, the program will establish a common system for planning and managing the following components: logistics (methods for prediction, storage, distribution and monitoring of drugs and laboratory materials), training (case management, microscopy, program management), supervision (frequency and content, microscopy quality control), monitoring (including recording and reporting) and evaluation. All partners will work closely through the TB Coordinating Team, chaired by WHO. Strengthening local capacity will be given priority. Human Resources Recruitment of staff – Essential health and support staff for the new TB centers and additional staff for the existing ones will be recruited to allow the implementing partners to deal with the increased workload and ensure services of adequate quality. All the organizations involved in TB control activities have been contacted in order to collect information on their needs and the recruitment of extra staff has been estimated on the expected patients’ intake for each TB center. To ensure an efficient supervision and monitoring of the overall program, WHO will recruit two international experts with full time dedication to the TB program: a TB Coordinator and a Laboratory Coordinator, who will be responsible for the overall management of the TB program and for all the laboratory activities (including training and smear quality control), respectively. Since the program plans to conduct quarterly supervisory visits to more than 30 TB centers, in addition to training and regular coordinating and evaluation activities (quarterly review meetings), the two Coordinators need to be sided by Supervisors, who will be recruited by one of the partners and seconded full time to the management structure of the program. Together with the staff seconded by the local health authorities (see “Strengthening of local capacity” section) they will form the TB Coordinating Team. Considering an average of four supervisions to each of the 30 - 35 TB centers per year with an average of one week for each visit (including travel time), for a total of 120 – 140 weeks of “supervision time” per year, the program needs to recruit at least 6 Supervisors, 3 for program and 3 for laboratory activities. Infrastructures and equipment Establishment and expansion of TB centers – In order to expand DOTS activities, new TB centers will be established and the expansion/rehabilitation of TB existing centers will take place. Several TB hospitals/centers have been severely damaged by the war. In hospitals like Burao, patients are forced to sleep outside even in winter. The furniture is old and in bad conditions. In other centers like Boroma and Eldere, the increasing number of patients determines the need of new wards (in Boroma a special ward is needed for the increasing number of suspected MDR TB cases). The water system in Galkayo TB hospital needs also renovation to provide water to the TB wards and laboratory. These interventions are expected to increase quantity and quality of the accommodation for TB inpatients, to facilitate access to these facilities, especially for nomadic patients and improve the adherence to DOTS. Procurement of furniture and equipment – The TB centers will be furnished and equipped with the items necessary for patients and care givers (beds, mattresses, chairs, bed sheets, blankets, mosquito nets, cooking utensils), examination and treatment (examination couches, trolleys, minor medical equipment, linen) and microscopy laboratory. The list of standard permanent equipment for performing microscopy at peripheral laboratory recommended by WHO (TB Handbook, WHO, 1998) has been used.


Training/Planning Training – The program will carry out extensive training for health personnel involved in DOTS expansion. The person in charge for each TB center will be trained as trainer in a TB training courses (diagnosis, treatment, case holding, information system) organized by WHO. After training they will conduct training for TB health workers in their respective TB units. Laboratory technicians will be trained on TB microscopy (collection of specimens, smear preparation, slide reading, recording and reporting of results). The teaching methodology will be skill- rather than knowledge-based. The WHO TB training modules “Managing TB at District Level” will be used. Within a few weeks after the training, the trainees will be visited in their health units in order to reinforce the impacts of the training courses. On the job training will continue throughout the duration of the program during the supervisory visits conducted every three months by the TB and Laboratory Supervisors in each TB center. Training of local staff will be given priority. In total, the program will train around 190 health personnel (120 clinical staff and 70 laboratory technicians) involved in TB control activities. Moreover, short orientation courses on TB case definition and management will be conducted for health personnel working in general health services (clinics, outreach services, etc.) and AFP surveillance teams. The health staff will thus be able to suspect possible cases of TB among the patients seen during their activities and direct them to the specialized treatment facilities. This will enhance the opportunities of detecting cases of TB among the patients attending the general health services. Partnership development - In order to ensure uniformity of implementation modalities among the different organizations and exchange their respective experiences, the existing SACB TB working group will be strengthened. At the beginning of the project a Participatory Planning Workshop will be conducted in order to draw the First Year Plan of Action, phase the implementation of activities, agree on standards, norms, tools and mechanisms for procurement, training, supervision and quality control. Quarterly Coordinating Meetings will be conducted among the Project Coordinators of the various organizations to review the status of implementation of their programs, revise indicators and targets, identify constraints and possible solutions. Strengthening of local capacity – At present the organizational structure for TB control within local authorities is very limited. Moreover, the division of the country in three different Zones with their respective provisional governments does not allow the identification of a single entity who can represent the whole country. In order to overcome these constraints and lay the basis for a future autonomous management of TB activities, the program will negotiate with each of the three Ministries of Health the secondment of two health staff to the program. They will be the counterparts of the TB, Laboratory Coordinators and Supervisors and will jointly participate in the planning, monitoring and evaluation activities in their respective areas. Together with the Supervisors, they will participate to a training course on TB control and laboratory methodologies (Arusha and Nairobi) and receive extensive support for their activities, in order to acquire the necessary competences and gradually take over the technical and managerial responsibilities and act as TB program managers within their respective ministries. Moreover, the program will recruit and train local staff at TB facilities, so that they will be able to gradually take over the management of the TB units. The program will support local health authorities in developing and implementing regulatory measures (already developed in Somaliland) to reduce the risk of emerging resistance through unregulated facilities/shops. Health education – TB patients detected and admitted for treatment will be given essential information on nature of TB, ways of transmission and treatment protocols. The aim is to improve patients’ compliance to chemotherapy and increase the cure rate. Appropriate IEC activities will be conducted for communities and key people (local authorities, teachers, traditional healers) focusing on early recognition of symptoms, health-seeking behaviors, preventive measures. While all efforts will be


done to ensure patient compliance to treatment, local authorities and families will be involved in patients’ defaulting/retrieval and assessment of close contacts of PTB (+) cases. Commodities/Products Provision of laboratory supplies - Laboratory reagents, sputum containers, etc. have been constantly supplied by WHO to the different TB centers. WHO will continue to be responsible for their joint procurement and distribution. Laboratory supplies requirement has been estimated on the expected number of microscopy examinations to be performed (see Annex 2). In case of approval of the grant, WHO will develop a procurement plan, tender to GMP suppliers and choose the best products on a competitive bidding basis. WHO will collect the items and store them in a central warehouse. Upon request from the TB centers, WHO will prepare the shipments and distribute them to the centers, bearing the cost for transportation. Each organization will request laboratory supplies every three months on the basis of the number of microscopy examinations performed. Printing of documents – The program will print and distribute guidelines, program documents, recording and reporting forms. The program will make sure than a sufficient supply of forms is available in each TB center. Culturally sensitive IEC materials, as well as international pamphlets/books on TB translated into Somali, will be produced and distributed to all TB centers. This material will be used for health education activities both for the patients and for the general population. Drugs Provision of anti-TB drugs - The efficiency of the drug management system in Somalia has been one of the major strengths of the TB program. Drugs are procured by WHO either directly or through external donors like the Global Drug Facility and the Norwegian Government. WHO will continue to be responsible for a joint procurement and distribution of drugs. The requirement of drugs has been calculated on the basis of the estimated number of patients to be treated, plus a buffer stock (see Annex 2). Procurement and distribution procedures will be similar to those described for laboratory supplies. Each organization will request drugs, every three months, on the basis of number and category of cases treated. Following WHO guidelines and recommendations, the TB control program, currently using 2 fixed drugs combination (RH), will shift towards the 4 fixed drugs combinations (HRZE). Monitoring and evaluation Supervisory activities – The members of the TB Coordinating Team (see “Recruitment of staff”) will conduct supervisory visits to each TB center every quarter in order to monitor key program activities. A standard checklist for supervisory visits will be adopted. The supervisors will: review all TB Treatment Cards, observe health workers doing their work, talk with health workers and TB patients, control the supplies (including food where provided), validate project reports data through a participatory approach involving interviews with the beneficiaries and the local counterparts. The supervisors will check the appropriateness of: diagnosis, classification and treatment of TB cases, management of supplies and health information system. At the end of the visit, the problems identified and the actions to be taken will be discussed with the TB unit staff. Similarly, the laboratory supervisors will monitor the laboratory activities and perform quality control of the microscopy. Each peripheral laboratory will keep all examined slides, out of which all smear positive slides and 10% of negative slides will be evaluated by the laboratory supervisors, both for microscopy result and for technical quality. Any discordant result and any remark on the quality of the smears will be discussed with the laboratory


technicians. The person in charge of the TB center will be informed of false-negative or false-positive results, for appropriate action. In case supervision is not possible due to security reasons, an analogous sample of slides will be sent to a referral laboratory for quality control. Supervisory visits will be used for conducting on the job training and the local staffs will be extensively involved as appropriate to strengthen local capacity. Findings and recommendations of each visit will be recorded to facilitate follow-up on actions taken and progresses achieved. Strengthening of TB information system – The implementing organizations will continue to use the standard recording and reporting system as laid down in the “Guidelines for Tuberculosis Control in Somalia”. Each organization will be responsible for ensuring the accuracy of recording and for timely submission of the required reports. A copy will be sent to TB Coordinating Team, which will compile and distribute (feedback) them. They will be analyzed and discussed during the quarterly meetings. In addition to the analysis of indicators adopted by the program for evaluation, further data will be collected and reviewed in order to monitor key program activities, identify areas requiring corrective measures and assess epidemiological trends. The program will collect and analyze data on: • Case notifications and trends by type, age, sex and geographical area; • Details of treatment outcomes for new smear-positive cases, relapses and re-

treatment cases; • Conversion rate at 2 (3) months of treatment for new smear-positive cases,

relapses and re-treatment cases; • Number of patients 12 years or older attending TB centers and number of TB

suspects among them; • Proportion of smear +ve cases among all notified new pulmonary cases; • Ratio of new smear +ve cases to new smear -ve and extrapulmonary cases; The morbidity data will be complemented with any available information on HIV prevalence among TB patients obtained through VCT (in order to ensure confidentiality and adequate supportive measures) and, whenever possible, with data on prevalence of mycobacterial primary drug resistance. External evaluation missions – Annual external assessment of program progress towards operational targets and epidemiological objectives will be undertaken. SACB will be the responsible body for its organization, with the participation of donor and all subjects involved in the TB control program. It will be based on the analysis of the data provided by the TB surveillance system, supplemented by supervision reports, training records and field visits to the TB centers. Interpretation of data and findings will enable conclusions to be drawn about general program trends, whether TB control activities are being carried out adequately and provide information for eventual adjustments. At the end of the program, a comprehensive TB Program Review will be conducted by a team of external consultants in association with the implementation partners. Operational research – Some information needed for measuring some impact and coverage indicators adopted by this program can be obtained only through operational research including epidemiological surveys. A community survey, conducted in the areas covered by the project, will be conducted in the first year of the program for estimating the burden of TB (tuberculin survey) and repeated in the fifth year to estimate the impact of the program. Collecting information on the local “emic” and developing an explanatory model about TB will be useful to develop more effective IEC messages, thus increasing detection and reducing defaulting. The program will conduct one joint operational research per year coordinated by the TB Coordination Team. Due to rapid increase of TB cases presenting with HIV infection in some areas of the country (North West Zone and most likely in the major urban settings), selected TB centers will be provided with HIV test kits in order to be able to screen the suspected cases of HIV by VCT and take the appropriate measures in accordance


with the joint HIV/AIDS strategic framework and zonal specific plans (under development).

26. Describe how the component adds to or complements activities already undertaken by the government, external donors, the private sector or other relevant partner: (e.g., does the component build on or scale-up existing programs; does the component aim to fill existing gaps in national programs; does the proposal fit within the National Plan; is there a clear link between the component and broader development policies and programmes such as Poverty Reduction Strategies or Sector-Wide Approaches, etc.) (2–3 paragraphs): The TB program in Somalia has been relying on NGOs and WHO support for several years. For the past 8 years, the fundamental elements of the program (provision of high quality drugs, basic training on DOTS, regular monitoring and supervision, surveillance) have been implemented to the best of the partners’ capacities. At present, there are 16 local and international organizations providing TB control services in collaboration with the local authorities. Essential for scaling up TB control in Somalia are the improvement of the ongoing activities and the expansion of DOTS activities, which are partly depending on an increase in access following positive developments of the peace process. The ongoing activities, though, can be only maintained with the resources available to the partners involved in TB control. All the organizations involved in TB control activities are included in the present proposal. A questionnaire for the assessment of the present situation and for the estimation of eventual additional resources needed by each organization for scaling up its activities has been submitted to each of them. The requests have been evaluated by the SACB TB Working Group for relevance, appropriateness, additionality and consistency with the objectives of the proposal. The accepted requests have been included in the overall proposal, which, therefore, represents the entirety of the Somali TB control program at present operational. All partners agreed on the plan to expand DOTS activities to cover larger sectors of the population and on the strategies to be adopted. The possible sites for expansion were identified assuming access to operations would remain/improve. However, as stated before, the available resources are not at all sufficient to cover the cost for DOTS expansion. The proposal therefore aims at filling the gap for DOTS expansion along with the plan agreed upon by all the partners involved in the program. The activities identified in the proposal are realistically identified to meet the objective. Training, regular provision of drugs and laboratory supplies and a strong monitoring structure will assist the implementing organizations to expand their activities without deteriorating the quality of services provided. Provision for additional staff and improvement of infrastructures has been taken care of. By the end of the program, the overall treatment capacity will increase up to about 14,500 TB cases per year, representing, respectively, 70% and 50 % of the expected new smear +ve and total TB cases of the country, a two fold increase of the services at present operational.

28. Describe innovative aspects to the component: (1–2 paragraphs) Although Somalia has been at war for over a decade, with consequent disruption of social services, absence of recognised government and wide areas of insecurity, the existing TB control program has achieved excellent results, comparable or superior to other countries with more favourable situations. TB control activities have been implemented by several national and international NGOs under the coordination and technical assistance provided by WHO. This proposal aims at further improving the existing activities by strengthening the present setup. All the partners involved in TB control activities have been consulted and are represented in the present proposal. They all will benefit from training and monitoring


activities and from provision of drug and lab material. The program foresees the establishment of a strong coordinating team able to ensure a continuous technical and managerial support to the implementing partners, regular support supervision, homogeneity of approaches and of implementation modalities. At the national level the program seeks to lay the basis for building the capacity of the local health authorities and personnel for gradually taking over the technical and managerial tasks required for program implementation. The utilization of 4 FDC will be introduced, thus facilitating prescriptions and improving patients’ compliance.

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

29.1 The involvement of beneficiaries TB patients will be involved in health education activities. They will be given essential information on nature of TB, treatment, necessity of DOTS, and way of transmission. The aim is to improve patients’ adherence to chemotherapy and increase the cure rate. Thanks to the first hand experience and the deep knowledge of the stigma related to the disease, former TB patients are usually excellent in advocacy and in interpersonal communications. As it has happened in the past, TB patients will be actively participating in IEC activities and will be encouraged to be active in their communities in providing information and education about transmission, prevention and adequate care seeking behaviors. They will also play an important role in early detection and referral of patients developing symptoms of the disease (from their families, villages or social settings).

29.2 Community participation

The communities living in the areas of intervention will play a crucial role in the successful achievement of the objectives of the program. The program aims at increasing the community awareness on the option of free quality TB treatment through program facilities rather than the use of self-prescription and of inadequate private facilities. Communities will be the beneficiaries of IEC activities and their collaboration will be sought in patients’ defaulting and retrieval. Somali communities are generally involved in TB control activities. Adherence to TB treatment is guaranteed for each patient by family members, clan leaders or religious authorities (in various locations communities/families are forwarding cash deposit at the beginning of the treatment of the patient, to be returned by the project on completion of the treatment). Communities assist and participate in events like World TB Day and are frequently involved in health education activities. Involvement of influential political leaders will be sought to reaffirm high level commitment to fight TB in Somalia.

29.3 Gender equality issues Recognizing the essential role of women in helping to curb TB infection within households, IEC activities will be mainly targeted to women. TB in Somalia affects more men (68%) than women (32%). Although these data reflect the sex distribution of TB on the global level, it is possible that access to TB health services in women may be limited by certain social factors, yet unknown. The analysis of records and reports will be disaggregated by gender. Operational research could be conducted to analyze eventual differences in access between sexes and identify the determinants of such differences. In addition, the organizations will seek gender balance during selection of trainees and recruitment of staff. Every effort will be made to ensure that they have equal


access to TB treatment. Women’s groups, schools, churches and other important forums will be used to emphasize the importance gender equality.

29.4 Social equality issues TB in Somalia affects the poorest sectors of the population. Refugees, returnees, IDPs, soldiers, PLWHA cases and malnourished individuals are the categories at highest risk for TB. By providing free services to all patients, the TB control program in Somalia tries to address social equality issues and to defend the right to health for all, allowing equal access for the poorest sector of the population, which will not be limited by economic factors. Despite the tensions and complexities of the political and clanic settings, equal access to all patients irrespective of their origin, clan, religion or political affiliation is one of the basic non negotiable principles of the Code of Conduct for all partners of the SACB network. This principle will be strongly defended and promoted through the provision of free services to all TB patients and through adequate advocacy campaigns.

29.5 Human Resources development Since the collapse of a Somali government in 1991, medical and nursing schools have been shut down. After more than a decade, no new institutions have been created to develop human resources within the country. The proposal aims at filling the existing gaps. Human resource development and capacity building is an intrinsic part of all the stages of implementation of this project. Local capacity will be built through the recruitment and training of all personnel involved in TB control activities while expanding general knowledge on TB diagnosis and control among general health staff (PHC, Hospitals). The staff responsible for TB units will participate to TB training courses organized and conducted by WHO. After training they will be responsible for training the TB health workers in their respective TB centers. Laboratory technicians will be trained on TB microscopy. The Program gives high priority to strengthening local technical and managerial capacities through recruitment and training of local personnel. It aims at gradually handing over the responsibilities to the local health authorities while maintaining the quality of the services.


SECTION V – Budget information 30. Indicate the summary of the financial resources requested from the Global Fund

by year and budget category: Table V.30

Resources needed (USD)

Year 1 Year 2 Year 3 (Estimate)

Year 4 (Estimate)

Year 5 (Estimate)

Total

Human Resources 1.236.876,00 1.249.776,0

0 1.301.556,001.308.756,0

0 1.314.156,0

0 6.411.120,00

Infrastructure/ Equipment 433.200,00 25.500,00 83.950,00 46.000,00 8.000,00 596.650,00

Training/ Planning 138.000,00 79.000,00 79.000,00 79.000,00 79.000,00 454.000,00

Commodities/ Products 220.900,00 40.585,00 73.715,00 77.072,00 109.360,00 521.632,00 Drugs 214.586,18 266.742,27 315.717,98 365.726,31 419.275,05 1.582.048,00

Monitoring & Evaluation 105.400,00 105.400,00 105.400,00 105.400,00 155.400,00 577.000,00

Administrative 182.224,09 141.864,31 154.676,75 155.594,87 161.609,40 795.969,00 Other (Car rental, Travel/transportations, Stationery, Running costs inclusive of Fuel/ Maintenance etc…) 325.980,00 325.980,00 325.980,00 325.980,00 325.980,00 1.629.900,00

Total 2.857.166,27 2.234.847,57 2.439.995,73 2.463.529,18 2.572.780,46 12.568.319,00 Contingency 285.716,63 223.484,76 243.999,57 246.352,92 257.278,05 1.256.831,90 Grand TOTAL 3.142.882,89 2.458.332,33 2.683.995,30 2.709.882,09 2.830.058,50 13.825.150,90

31. For drugs and commodities/products, specify in the table below the use of the

commodity, unit costs, volumes and total costs, for the FIRST YEAR ONLY: Table V.31

Item/unit Purpose Unit cost (USD) Unit Volume Total cost

(USD) Drugs HRZE (75+150+400+275) TB Rx 36.60 1,000 2,755,125 100,838HR tab (75+150) TB Rx 13.80 1,000 8,087,625 111,609Pyrazinamide tab (400 mg) TB Rx 15.17 1,000 888,750 13,481Streptomycin vial (1 g) TB Rx 3.24 50 44,438 2,880Ethambutol tab (400 mg) TB Rx 13.10 1,000 325,875 4,270

Subtotal 233,077Laboratory materials and reagents Sputum cont., plastic w lid Lab exam 0.07 1 338,910 23,724Labels for containers Lab exam 0.02 1 338,910 6,778Slides for microscope Lab exam 99.06 5,000 338,910 6,714Applicators, wooden Lab exam 2.32 1,000 338,910 786Acid-ethanol (litres) Lab exam 10.00 1 339 3,389Carbon fuchsin (litres) Lab exam 18.49 1 678 12,533Methylene blue (100 ml) Lab exam 1.45 1 452 6,554Immersion oil (100 ml) Lab exam 8.80 1 226 1,988Xylene or toluene (100 ml) Lab exam 0.60 1 226 136


Lens paper (100 pcs) Lab exam 2.39 1 226 540Cotton wool abs. (500 gr) Lab exam 1.26 1 113 142Filter paper (100 pcs) Lab exam 6.61 1 452 2,987Toilet tissue (roll) Lab exam 0.20 1 226 45Pens, ball point, black ink Lab exam 0.15 1 452 68Pens, ball point, red ink Lab exam 0.13 1 226 29Sodium hypochlorite (litres) Lab exam 0.62 1 1,130 700Methylated spirit (litres) Lab exam 4.90 1 226 1,107

Subtotal 68,222

Item/unit Purpose Unit cost (USD) Unit Volume Total cost

(USD) Recording and reporting forms TB lab form: request for sputum examination TB Inf. Sys. 0.01 1 86.268 863

TB treatment card TB Inf. Sys. 0.20 1 9.480 1,896TB identity card TB Inf. Sys. 0.10 1 9.480 948TB referral/transfer form TB Inf. Sys. 0.80 1 948 758TB register TB Inf. Sys. 8.00 1 30 336TB laboratory register TB Inf. Sys. 8.00 1 30 336

Subtotal 5,137Material for streptomycin inj. Syringes TB Rx 2.75 100 44,437 1,222Needles TB Rx 1.43 100 44,437 635Water for inj TB Rx 2.90 100 44,437 1,289Gloves TB Rx 2.26 100 44,437 1,004

Subtotal 4,150Various IEC Material IEC Activ. 20,000Internal Transport Drugs Deliv 60,000Furniture 124,300Beddings 56,600Miscellaneous

Establish / Upgrade TB Centers

Lump sum

40,000Subtotal 300,900

Matching Funds -176,000 Total Cost of Drugs and Commodities/Products 435,486

31.1 Budget justification: Please indicate assumptions or formulas used to

calculate volume of drug/commodity necessary to achieve coverage targets specified in section 26.

Please see Annex 2

31.2 In cases where Human Resources (HR) is an important share of the

budget, explain to what extent HR spending will strengthen health systems capacity at the patient/target population level, and how these salaries will be sustained after the proposal period is over (1 paragraph):

The human resources component accounts for 46% of the total funds requested. A fair share of this component covers the staff responsible for coordinating, training, supervising and monitoring the program, essential to ensure an adequate standard. In a country under complex emergency situation like Somalia, the proposed amount of money will guarantee continuation of TB activities for the duration of the program. It is hoped that in the meantime Somalia will be able to find a political solution to its internal problems. If this is achieved, the future government of Somalia, with the help of external donors, will be able to sustain the salaries of the staff supported by the GFATM.


32. If you are receiving funding from other sources than the Global Fund for

activities related to this component, indicate in the Table below overall funding received over the past three years as well as expected funding until 2006 in US dollars:

Table V.32 2000 2001 2002 2003 2004 2005 2006 Domestic (public & private)

N/K N/K N/K N/K N/K N/K N/K

External 1,448,000 1,468,000 1,758,360 1,830,366 1,822,566 1,723,502 1,661,000

Total

33. Provide a full and detailed budget as attachment, which should reflect the broad

budget categories mentioned above as well as the component’s activities. It should include unit costs and volumes, where appropriate.

Please see Annex 5

34. Indicate in the Table below how the requested resources will be allocated to the

implementing partners, in percentage: Table V.34

Resource allocation to implementing partners* (%)

Year 1 Year 2 Year 3 (Estimate)

Year 4 (Estimate)

Year 5 (Estimate) Total

Government 7.1 7.5 8.3 6.8 6.5 6.6 NGOs/ Community-Based Org.

62.3 59.0 58.2 56.0 53.9 61.7

Private Sector 5.1 4.6 4.2 5.1 4.0 4.2

People living with HIV/TB/ malaria

Academic/ Educational Organisations

Faith-based Organisations 6.9 6.9 6.3 6.5 6.0 6.0

Others (WHO) 18.6 22.0 23.0 25.6 29.6 21.5

Total 100% 100% 100% 100% 100% 100%

Total in USD 2.857.166 2.234.848 2.439.996 2.463.529 2.572.780 13.825.151

Please note that a detailed one year work plan and an indicative work plan for the second year need to be provided with detailed budget. See template in Annex B to this form.


SECTION VI – Programmatic and Financial management information 35. Identify your Principal Recipient(s) (PR)

Table VI.35 Name of PR World Health Organization (WHO)

Name of contact Dr. Hashim Suleman

Dr. Bashir Suleman

Address WHO Somalia Hargheisa, PO BOX 653

Telephone +252 8 283030 +252 8 283030 / 7147 Fax +252 213 E-mail [email protected] [email protected]

35.1 Briefly describe why you think this/these organization(s) is/are best suited to undertake the role of a Principal Recipient for your proposal/component (e.g. previous experience in similar functions, capacity and systems in place, existing contacts with sub recipients etc) (1–2 paragraphs) The World Health Organization for Somalia has been involved in TB control in Somalia since the inception of TB activities in 1994. WHO has played a pivotal role in building partnership and in coordinating the implementation of the program on the field, by supporting all TB centers with drugs and lab supplies and by ensuring training and regular monitoring and supervision. The following reasons explain why WHO Somalia is considered a suitable Principal Recipient for the TB component: - WHO Somalia’s mandate is clearly related to health and includes strong

commitment against TB - WHO Somalia has proven experience with grant management with

adequate absorptive capacity - WHO Somalia has efficient procurement systems that can guarantee quality

of commodities in accordance with international standards - WHO Somalia has existing technical and financial arrangements with a large

number of NGOs in Somalia - WHO Somalia has good working relations with local authorities in Somalia

as well as with other organizations which promote coordination and inter-sectoral action

35.2 Briefly describe how your suggested Principal Recipient(s) will relate to

the CCM and to other implementing partners (e.g., reporting back to the CCM, disbursing funds to sub-recipients, etc.) (1 paragraph) The implementing organizations will be financially and programmatically accountable to the Principal Recipient, who will report quarterly to the SACB Health Sector Committee on programmatic and financial issues related to the implementation of the proposal. As far as disbursement of funds is concerned, WHO Somalia will adopt the same financial system that has been used in the past with all relevant partners in Somalia. The Principal Recipient will enter into agreement with each approved sub-recipient; funds will be disbursed on an installment basis and recipients will be requested to provide programmatic and financial reporting to WHO Somalia. The reports produced by the partners will be used for regular feedback to the GF and the Local Fund Agency.


36. Describe the proposed management arrangements (outline proposal implementation arrangements, roles and responsibilities of different partners and their relations) (1–2 paragraphs) The implementation frame of the present proposal is based on the best information available on the organizations at present operational and on the existing political and security situation in the country. Since Somalia is experiencing a complex emergency situation, the access to various areas varies frequently and unexpectedly. At the beginning of the program the SACB TB Coordinating Team and the implementing partners will jointly conduct a new situation analysis, which might lead to a partial modification of the present implementation frame (for example locations not longer accessible or new areas which reached stability). All partner organizations agreed to consider the present plan of action (and subsequent budget allocation) as provisional and subject to modification according to the situation existing at the time. For the same reasons, the action plan might be modified during the implementation of the program. The request of contingency funds to tackle unexpected and unforeseeable events is justified by the above considerations. Technical, logistic and financial management of the overall program will be responsibility of the TB Coordinating Team (TBCT), which will be composed of staff recruited by different partners (WHO, CCM-Italy, counterparts) and seconded full time to SACB. The following table shows the composition of the TBCT. See also Section 26.3 for respective roles and responsibilities related to monitoring and evaluation activities.

Staff Recruiting org 1 TB Coordinator 1 Laboratory Coordinator 3 TB Supervisors 3 Laboratory Supervisors 3 TB Counterparts 3 Laboratory Counterparts 4 Administrative/Financial support staff

WHO WHO CCM - Italy CCM - Italy Local Health Authorities Local Health Authorities WHO

Each implementing organization will prepare quarterly activity and financial reports and submit them to the TBCT, who will assess the performance of each location, supplementing the information with findings from SPV reports. The outcomes will be discussed individually with each organization and in plenary session during the Quarterly Review Meetings (QRMs). The TBCT will also prepare quarterly activity and financial reports related to its own activities (training, SPV, quality control, procurement, etc.), which will be presented and discussed in the QRMs. The TBCT will be responsible to the SACB - TB Monitoring Group (SACB-TBMG), formed by members of SACB partner agencies, who will monitor and evaluate the performances of the program and ensure that the funds are allocated and used in a transparent and accountable manner. Disbursement of further installments will be subject to positive evaluation of activity and financial reports. To avoid conflicts of interest, the members will be selected among the various agencies (donors, UN Agencies, INGOs, local authorities, other international and regional bodies) who are part of the SACB but are not directly involved in the management and implementation of the program. A representative of the LFA will be a permanent member of the group. The SACB-TBMG will participate to the QRMs and held extra meetings whenever needs arise. 36.1 Explain the rationale behind the proposed arrangements (e.g., explain why

you have opted for that particular management arrangement) (1 paragraph)

The TB Coordinating Team (TBCT), led by the Principal Recipient, will ensure the coordination of the activities, provision of technical support to the


implementing organizations, and a regular monitoring of their activities. The presence of the main donors within the SACB - TB Monitoring Group will ensure adequate information sharing on all available funding for health projects, so as to avoid duplication and overlapping of activities and funding. The proposed arrangements will allow the active involvement and participation of all main actors involved in TB control activities in Somalia and, at the same time, guarantees an external and neutral monitoring and evaluation of the programmatic and financial management of the program.

37. Briefly indicate links between the overall implementation arrangements described above and other existing arrangements (including, for example, details on annual auditing and other related deadlines). If required, indicate areas where you require additional resources from the Global Fund to strengthen managerial and implementation capacity (1–2 paragraphs) The proposed arrangement builds on the already existing capacities and expertise of the partners involved. WHO will continue to be responsible for procurement and distribution of drugs and laboratory materials and for the supervision, monitoring and evaluation component of the program, which will be strengthened by the establishment of a team who involves the major stakeholders. An office with essential staff and facilities will be set up to ensure administrative, financial and logistic support to the program. Additional resources are requested to the GF for the recruitment of the staff, for the establishment of the office and for covering its running costs.


SECTION VII – Monitoring and evaluation information

38. Outline the plan for conducting monitoring and evaluation including the following information (1 paragraph per sub-question).

38.1 Explain the overall approach to M&E The reporting system currently adopted by the Somalia TB Program as laid down in the “Guidelines for TB control in Somalia” will be further strengthened. Standard recording and reporting forms will be used to collect the necessary information and to monitor and evaluate programme activities. All implementing organization will register, at each TB center, relevant information on TB patients. Each quarter, they will send the reports to the TB Coordinating Team where the overall information will be compiled and kept as general database. During the Quarterly Review Meetings, the data will be analyzed and discussed by all implementing organizations so as to monitor the programme activities closely. The information through the TB surveillance system will also be integrated by activity and supervision reports. In addition, external evaluation of program activities will take place annually by using the data provided through the TB surveillance system, supplemented by supervision reports, training records and field visits to TB centers. Interpretation of the data and findings will enable to draw conclusions about general program trends, assess whether TB control activities are being carried out adequately and forward recommendations on eventual adjustments. A comprehensive TB Program Review will be conducted in year five. In order to measure the impact indicator (incidence of smear +ve cases per 100,000 population) two Tuberculin surveys will be conducted at the beginning and at the end of the project period. The geographical analysis of the registrations, will allow to draw a graphical representation of the area and to perform a spatial analysis of some important features, like catchment areas and TB clustering. Timeline Start of project

• Planning Workshop with all relevant stakeholders (drawing of First Year Plan of Action, phasing implementation of activities, setting standards, norms, tools and mechanisms for procurement, training, supervision, quality control)

• Collection of baseline data • Tuberculin survey

On-going • Case recording Quarterly

• Quarterly Reports on case detection and treatment outcome

• Reporting on project implementation (activities, supervision, quality control reports)

• Quarterly Review Meeting Annually • External evaluation of the programme activities

• Participatory project evaluation and re-planning • Development of an annual report of the programme

In year five • Tuberculin survey • TB Programme Review

38.2 Describe how the beneficiaries will be involved in M&E


As part of routine supervisory activities, non-structured interviews with patients are performed to assess the level of health education and the grade of satisfaction with regard to the services provided in the TB centers/hospitals. Key community representatives and stakeholders will be motivated to participate in planning and in annual evaluation activities. Communities leaders will be involved in collection of demographic information, patients defaulting/retrieval, contact detection. They will receive feedback on presence and extent of TB in their respective communities and project results. Operational studies on determinants on health seeking behaviour, local explanatory models of TB and variables related to access to health services will entail the full involvement of patients and communities.

38.3 Describe how the CCM or other partners will be involved in M&E (e.g., oversight, data review, capacity building, quality control and validation of data). To ensure an adequate quality of data, extensive training on TB surveillance system will take place during the training courses for each categories of health personnel such as TB coordinators, TB center responsible officers and laboratory technicians. The programme will print the recording and reporting forms and ensure their regular supply to all implementing organizations. Standardization of data collection and reporting tools coupled with training of staff on their use will guarantee an adequate quality of information. Regular joint supervision and shared analysis of reports will allow identification of mistakes, inaccuracy and inconsistencies in the data collected, thus allowing their validation. Quality of microscopy will be ensured by a control system which allows the validation of the smear results. WHO, in close collaboration with the other partners of the SACB TBCT will coordinate training, research and evaluation activities, thus ensuring adequate standards in terms of contents and methodologies. As mentioned before (26.3 – Recruitment of staff), proper supervision and monitoring requires an adequate number of staff which can guarantee a regular presence in the field. The Coordinating Team will be formed by WHO Coordinators who will be supported in their activities by Supervisors. The SACB partners have agreed to select one partner organisation (CCM-Italy), which does not have ongoing TB activities in Somalia and has previous experience in TB implementation and monitoring activities, to provide the needed expertise. The Supervisors will be recruited by the responsible organisation and seconded full time to the SACB TB Coordinating Team. CCM-Italy will be involved only in this component, thus guaranteeing a maximal neutrality and transparency in the supervision, monitoring and evaluation process.

38.4 Describe what already exists. How does the existing health information system work and how it will be used to manage and/or report proposal data Since 1995 the TB control program in Somalia has an efficient and comprehensive system for data collection. The percentage of notified cases evaluated for treatment outcome showed constant increase, from 58% in 1997 to 97% in 2001. Notified TB cases are registered on standard district registers at each TB center/hospital. Three standard reporting forms (on case notification, sputum conversion and treatment outcome) are compiled by the TB coordinator of each TB center/hospital and submitted to WHO Somalia on a quarterly basis. Data are then entered in the national database for analysis and follow up by the WHO TB Medical Officer. All other relevant information on TB centers/hospitals is collected by the WHO Medical Officer through regular supervisory missions.


38.5 Prepare a table showing the following for each impact, coverage and process indicator listed in section 26: i) the source of data, ii) periodicity of data collection, iii) how the quality of data will be determined/ensured, iv) who (the entity) will be primarily responsible for each indicator, v) and what indicators will be reported through partner organisations.

Indicators Source of data Periodicity Data

validation Respons.

Reported through partner

orgs Incidence of smear +ve cases per 100,000 populat.

Tuberculin surveys 5 years WHO

Number and % of new smear +ve TB cases detected under DOTS

TB Inform. System Quarterly SPV visits

Data analysis Impl. Orgs. TBCT * X

Number and % of estimated total new TB patients detected under DOTS


Data analysis Impl. Orgs. TBCT X

Number and % of TB centers implementing DOTS



Number and % of smear +ve cases successfully treated



Number and % of TB cases defaulting



Number and % of TB centers with adequate staffing

Activity rep. SPV rep. Quarterly SPV visits Impl. Orgs.

TBCT X

Number and % of managerial staff in place Activity rep. Annually External eval. TBCT

Local auth.

Number of new TB centers establish. or expanded


TBCT X

Number and % of TB centers with adequate lab equipment


TBCT X

Number and % of health staff trained in DOTS

Train. rep. SPV rep. Quarterly External eval. TBCT

Number and % of lab techn. trained in microscopy

Train. rep. SPV rep. Quarterly External eval. TBCT

Number and % of planned coord. activities conducted Activity rep. Quarterly External eval. TBCT

Number of local staff with managerial responsibilities

Activity rep. SPV rep Quarterly

SPV visits Data analysis External eval.

Impl. Orgs. TBCT Local auth.

X

Number and % of patients with basic knowledge on TB

Activity rep. SPV rep Quarterly SPV visits Impl. Orgs.

TBCT X

Number and % of TB centers with stock-out of laboratory supplies

Activity rep. SPV rep Quarterly SPV visits


Number and % of TB centers with stock-out of IEC and TB IS materials



Number and % of TB centers with stock-out of TB drugs



% of drugs having expired in stock by type


Data analysis

Impl. Orgs. TBCT WHO

X

Average number of SPV visits per TB center

Activity rep. Annually External eval. TBCT

Proportion of evaluated smears correctly read SPV rep Quarterly SPV visits

Quality control TBCT

Number and proportion of TB units submitting accurate, complete and timely reports

TB Inform. System Quarterly External eval. TBCT

Prop. of planned operational researches conducted Activity rep. Annually External eval. TBCT

• TB Coordinating Team


38.6 Describe how data will be analyzed and used by the PR, CCM, and others Results of monitoring and evaluation activities will be used to review project results and constraints in order to strengthening weak components, modifying implementation modalities and identifying alternative approaches. They will be shared with all partners and form the basis for the preparation of following Yearly Action Plans. Results from operational researches will allow a more accurate estimation of TB situation and trend, revision of targets, quality and impact of the project, decision on program expansion.

39. Recognizing that M & E plans will make use of existing monitoring systems especially for impact and coverage indicators, national information systems may require strengthening. Please specify activities, partners and resource requirements for strengthening M&E capacities.

Note: The activities reported in the following table are only those grouped under the M&E component. Other resources listed under different budget lines aimed at strengthening M&E activities include: recruitment of supervisory staff, training of managerial and clinical personnel, planning workshops and QRMs, procurement of TB information system material, procurement of computers. Further activities (operational researches, and annual external evaluations) are covered by WHO as matching funds.

Please note: Total requested from Global Fund should be consistent with the resources needed for Monitoring and Evaluation as indicated in Table V.30. Examples of activities include collecting data, improving computer systems, analyzing data, preparing reports, etc.

Table VII.39

Resources Required (USD) Activities (aimed at strengthening Monitoring and Evaluation Systems)

Partner(s) (which may help in strengthening M&E capacities)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

TB Progr. Rev. 50,000 50,000

Transport 86,400 86,400 86,400 86,400 86,400 432,000

Audit 19,000 19,000 19,000 19,000 19,000 95,000

Global Fund M&E request 105,400 105,400 105,400 105,400 155,400 577,000

Unmet need

Total resources needed


SECTION VIII – Procurement and supply-chain management information 40. Describe your plans for procurement and supply chain management of health

products (including pharmaceutical products, diagnostic technologies and other supplies related to the use of medicines, bednets, insecticides, aerial sprays against mosquitoes, other products for prevention [e.g., condoms], and laboratory equipment and support products [e.g., microscopes and reagents]) integral to this component’s proposed disease interventions. The plan should include.

i. Procurement responsibilities - The anti-TB drugs and laboratory material will be

procured by WHO using its standard procedures for tendering and quality control.

ii. Procurement practices - For the procurement of drugs the Global Drug Facility will be utilized.

iii. Supply chain management - The distribution system in place in Somalia has

guaranteed uninterrupted supply of drugs/lab supplies to all TB centers for several years. Delays in distribution have occurred in the past and may still occur due to insecurity conditions.

iv. Avoidance of diversion – Each TB center will be responsible for establishing a

proper supply management system. Quarterly reports on supplies received and used will be prepared and sent to the TB Coordinating Team. During the supervisory visits, supply management will be monitored and the consumption will be crosschecked with the TB and laboratory registers and reports. Supply management will also be regularly monitored at central and intermediate levels. The use of FDC preparations will reduce the risk of drug misuse.

v. Forecasting and inventory management - The estimation of drugs and laboratory

supplies needed by each TB center will be updated on quarterly basis by analyzing the respective reports on number and category of cases under treatment. The expected consumptions will be compared with the quarterly reports on stock balance prepared by each center to identify eventual inconsistencies. Monitoring of stock management will be part of supervisory visits. A reserve stock will be kept at all levels of the system: a 6-month supply at central level and a 3-month supply at intermediate and at tuberculosis management levels.

vi. Product selection – The health products to be procured by the program include:

anti-TB drugs, laboratory materials and reagents, recording and reporting forms. The WHO-recommended formulations of anti-TB drugs (including FDC) and treatment protocols will be used.

vii. Donation programmes - In the absence of a stable government in Somalia, drug

provision is fully dependent on external donors. Drugs requested via the Global Fund will therefore be complementary to the drugs donated by WHO Somalia, by the Norwegian Government and by the Global Drug Facility. While WHO will continue the provision of anti TB drugs for the Somalia TB program in 2003-2004-2005, the Norwegian support will stop in 2003 and GDF provision will be subjected to the decision of a review mission in 2003.

viii. Compliance with quality standards - According to WHO/GDF best practices. The

program will obtain the drugs through the Global Drug Facility, which guarantees drugs of recommended strengths and proven quality.


ix. Adherence to treatment protocols, drug resistance, and adverse drug reactions Adherence to treatment protocols will be ensured by strict DOTS implementation. Patients’ compliance will be strengthened by regular IEC activities conducted for patients and communities. Defaulting will be minimized by involvement of communities and the use of the “grantor” system commonly adopted with good results in Somalia. The use of FDC will increase compliance with treatment by reducing the number of tablets to be taken and simplifying prescription. At the same time, the risk of drug resistance, caused by erratic drug intake and use of mono-therapy will be virtually eliminated. Eventual adverse drug reactions will be monitored by the health staff that will be trained on recognizing related symptoms. Appropriate measures will be taken accordingly. Each center will keep a small stock of single drugs in case adverse reaction to FDC preparation should arise.

x. National and international laws – Anti-TB non-proprietary drugs will be purchased

by the program.

xi. Procurement and supply management indicators - The following indicators will be used to monitor procurement and supply management:

• Average lead time between product orders and receipt of goods at central,

intermediate and peripheral level; • Average percentage of time out of stock of products at central and

intermediate warehouses; • Number and % of TB centers with stock-out of TB drugs; • Percentage of drugs having expired in stock at central, intermediate and

peripheral level; • Number and % of TB centers with stock-out of laboratory supplies.

Documents

Strengthening TB Control Activities in Somalia - The Global Fund …docs.theglobalfund.org/program-documents/GF_PD_001_bb... · 2017. 3. 30. · 14 . Contact persons ... World Bank,