UPHOLD Strategy for Tuberculosis Control 2006/2007

Status Report May 2007

Presentation to Ministry of Health Officials

Overview of the Presentation

• Introduction/background• Strategy for TB control • TB control Activities • Results/Achievements• Challenges• Lessons learned• Way forward

Introduction and background (1)

• UPHOLD -Uganda Program for Human and Holistic Development• UPHOLD is a USAID funded project• Overall project aim- increase access and utilization of sustainable

and quality social services • Education, Health and HIV/AIDS in support of USAID’s Strategic

Objective 8(aims to improve human capacity)• Assist Ugandans to achieve Improved health, longer and more

productive lives• USAID resources for TB have increased each year and now total

over $408 million making it the largest donor in this area

Introduction and background (2)

• Currently operates in 34 districts (up from 20), covering 42%

• Uganda’s population ~ 11.8m people, Has six Regional Offices and one satellite office

• geographical situated in all regions of the country

Introduction and background (3)

• UPHOLD implements activities with a focus on ‘4 Rs’:

Results at people levelResponsible speed in implementationRegional leadership and accountabilityReaching out to and working principally with

Ugandan institutions and systems

• UPHOLD’s core technical areas of implementation include: • HIV/AIDS• Primary School Education• Child Health• Integrated Reproductive Health• Adolescent Health• Communicable Disease Control- Malaria and

Tuberculosis

Introduction and background (2)

AfghanistanBangladesh

Brazil

Cambodia

China

DR Congo

Ethiopia

India

Indonesia

Kenya

Mozambique

Myanmar

Nigeria

Pakistan

Philippines

Russian Federation

South Africa

Thailand

Uganda

UR Tanzania

Viet Nam

Zimbabwe

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DOTS case detection rate (new smear-positive, %)

Tre

atm

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succ

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Target zone

TB High Burden countries 2004/2005

Tuberculosis Situation in Uganda

• Est. ARI of 3%. Annual prevalence of 300-330/100,000 incidence of M + of 150-165/100,000

• HIV: it is estimated that 60% of TB patients are dually infected. (UPHOLD Records)

Tuberculosis Situation in Uganda

• Uganda has adopted the following WHO objective– Case detection rate of 70%– Treatment success Rate of 85%– Uganda aims at achieving the above objectives

implementing the DOTS strategy with a community based TB Care Approach

Community-based TB CareReferral System in rural settings

DDHS's Office / DTLS

Diagnostic CentreMicroscopy Unit

Sub-countyHealth Worker

Parish Committeeor L.C. II

Community Volunteer

TB Patient

DOT

MobilizationSupervision

MobilizationHealth Education

Follow-up

Identification Community Volunteer

( Health Assistant / Health Educator / Health Visitor / Leprosy Supervisor )

Support supervision& drugs to C.V.

Sputum smearfollow-up

Report on drugs& treatment outcome

NotificationDrug supplyFollow-up

Support supervisionDrugs / Supplies

Report on: case-finding,sputum conversion rate,treatment outcome, use of drugs.

Training & Support supervisionManagement of resourcesReports on cohort analysis

Feed back

Support supervision& drugs to C.V.

DDHS

Ministry of HealthNational Tuberculosis& Leprosy Programme

Baseline Targets

Level Case Detection rate(%)

Treatment success rate(%)

WHO/National Targets

70 85

National target achieved

49 (2006) 73 (2005)

Targets for UPHOLD supported districts

42 (2006) 78(2005)

Start up

• UPHOLD Received $690,000 for FY 2006/2007 to support the control of TB in all the 34 UPHOLD supported districts

• Activity implementation was rolled out in October 2006 at district level

Strategy

Collaboration with other stake holders Districts, NGOs and CBOs to;

• scale up CB DOTS,• Improving diagnostics,• Support BCC (Prevention, treatment and control),• Support private sector involvement in TB,• Explore potential collaboration and involvement of schools

in control of TB,• Support communities to embrace CB DOTS.

• Previously AIM supported districts- Consolidate and Build on what AIM left in place

• NUMAT-UPHOLD-Initiate Activities and eventually handover to NUMAT

• UPHOLD only- Implement activities up to the end of the project

• District TB profiles -CDR, TSR, DTUs, TUs etc

Application of the strategic Approach

Category Districts

UPHOLD, prev. AIM supported

Pallisa, Budaka, Koboko Marcha/Terego, Yumbe, Mubende, Mityana, Bushenyi, Rukungiri

UPHOLD-NUMAT ( red-prev. aim)

Lira, Dokolo, Amolatar, Katakwi, Amuria, Gulu, Amuru, Kitgum, Arua

UPHOLD only Bugiri, Mayuge, Kamuli, Kaliro, Mbarara, Kiruhura, Isingiro, Ibanda, Wakiso, Luwero, Nakaseke, Rakai, Lyantonde, Nakapiripirit, Bundibugyo, Kyenjojo

Objectives

• Achieve the WHO targets for TB case detection and cure rates.70 % CDR and 85% Treatment success rate

• UPHOLD -5% Increase in CDR and 10% increase in TSR from the base line indicators

• Strengthen the ability of the country to expand the use of proven and cost-effective interventions of the DOTS strategy

Activities

• Build capacity for CB DOTS services in sub countiesTB/HIV case management at health facilitiesTB drug logistics management at health facility level• Support Supervision activities at health facility-recording,

drugs, case management• Support supervision and delivery of anti TB drugs and

community levels.• Monitoring Implementation of activities

• Activity implementation was rolled out in October 2006 at district level

Methodology

• Districts planned, budgeted and scheduled for TB control activities

• Involved Central and district facilitators in the trainings

• Used National TB guidelines and training materials• UPHOLD Funded the activities• Technical assistance• On going monitoring and will do an Evaluation

Outputs

Trained• 382 Health workers in TB drug logistics• 342 in CB DOTS/HIVSupervisions• Supervision by DTLS in 91 HSDs • HFs supervised by HSD Focal persons• 422 sub counties supervised including town councils by

SCHWS• 48% of patients on CB DOTS( ranging from 10% to 90%)

Results/Achievements in 1st Quarter 2007

Case Notification• 3,763 TB patients of all forms• 2163 Smear positive TB patients• Case Detection rate 50% from 42% • Two fold increase in districts with CDR greater than

70%

Results -Case Detection rate

• 2006 CDR • 2007 CDR 1st Qtr

Below target, CDR< 70%

Above Target > 70%

Comparison of TB case detection rates 2006 and 2007

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Districts

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CDR 2006 in %

CDR(%)

Comparison of TB case detection rate for 2006 and 1st Qtr 2007

Results TB/HIV collaboration

TB/HIV Collaboration• All districts are implementing the TB/HIV

collaboration in varying degrees according to TB/HIV policy

• 1753 (47%) of TB patients are testing for HIV • 1051 (60%) of all the TB patients test positive

Results –Treatment outcome

Case holding• CB DOTS coverage per patient is 48% (District

Reports)• Treatment success rate 78%( No change)• However more districts have TSR ≥85% (11

districts as compared to 4 last year)

1st Quarter 2006 TB treatment Outcomes in UPHOLD supported Districts

Cured34%

Completed44%

Died6%

Failure0%

Defaulted12%

Transferred4%

Results-Treatment success rate

• 2005 2006 1st Quarter

Above target, TSR≥ 85% Below target, TSR< 85%

Challenges

• Poor implementation of the TB/HIV Collaborationo CPT numbers not known at the beginning of treatmento TB cases on ART not known• Inadequate Supervision at all levels• Small no. of patients on CB DOTS• Inadequate Coordination with other partners• Stock-out of essential supplies (e.g., HIV test kits, CPT)• Changes in district capacity to implement due to

redistricting,• Restructuring- position of DTLS is threatened• Insecurity in the North and the Northeast parts of the

country

Lessons learned

• MOH as a stake holder in implementation of TB control activities

• District support is necessary in implementation of TB activities

• ?Training and Supervision can lead to an increase is CDR

Way forward

• Extension for one year• Improve the quality, access and utilisation of key

preventive and curative TB services,• Consolidating CB TB DOTS.• Strengthen the capacity of CVs and health workers thru

CMEs, refresher training, and support supervision• Provision of job-aides, registers, implementation guidelines

and policy/strategy documents to Volunteers and health workers

• Strengthen TB/HIV collaboration

Thank you