WHO/CDS/TB/2002.303 DISTR.: LIMITED ENGLISH ONLY
F INAL R EPORT OF THE
2
NDM EETING OF THE DOTS E XPANSION
W ORKING G ROUP
Wednesday, 31 October 2001 Palais Des Congrès, Paris, France
World Health Organization Communicable Diseases
Stop TB
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© World Health Organization 2002
This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced, or translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes.
The views expressed herein by named authors are solely the responsibility of those authors.
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Acknowledgements
This document was prepared by Karen Palmer and Leopold Blanc of the WHO secretariat on behalf of the DOTS Expansion Working Group, with assistance from S. Egwaga, Rapporteur of the meeting, Mario Raviglione and J.W. Lee.
Thanks to all members of the DOTS Expansion Working Group, and other participants, for their contributions to the success of this meeting. The secretarial assistance of Cinzia Delaunay in preparing this report is gratefully acknowledged. The meeting was in part financially supported by the Global Bureau for Population, Health and Nutrition, US Agency for International Development and partly by WHO.
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Table of Contents
I. Introduction...6
II. Proceedings...6
III. Summaries of presentations...6
A. Global DOTS Expansion Plan...6
B. Regional planning...7
C. Country planning...8
1. Development of national plans...8
2. Estimation of national financial needs and gaps...8
3. Development of partnerships and National Interagency Coordinating Committees...8
4. DOTS expansion constraints and opportunities...8
D. Achievements and plans of the DOTS Expansion Working Group...9
E. Presentations by Partners and and Stop TB Secretariat...10
IV. Progress in global TB control...10
V. Conclusions and proposed actions...11
A. Actions proposed for countries and regions, November 2001-October 2002...11
B. Actions proposed for technical partners, November 2001-October 2002...12
C. Actions proposed for financial partners, November 2001-October 2002...12
D. Actions proposed for WHO, November 2001-October 2002...12
Annex 1: Opening and welcome speech, by Dr. J.W. Lee...13
Annex 2: Global DOTS Expansion Plan: concept and progress, by Dr. Mario Raviglione...17
Annex 3: Plenary session: summary of poster presentations...23
Annex 4: Presentations...27
Annex 5: DOTS Expansion Working Group plan, by Dr. Leopold Blanc...37
Annex 6: DOTS Expansion Working Group conclusions...41
Annex 7: List of meeting participants...43
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I. Introduction
The 2nd meeting of the DOTS Expansion Working Group of the Stop TB Partnership was held on October 31, 2001 in Paris, France at the Palais des Congrès. The meeting was attended by 146 people including National TB Programme (NTP) managers of all (with the exception of India) 22 high-burden countries (HBC), all main technical partners, most financial partners, and the WHO network for DOTS expansion at the regional and country offices. The complete list of participants is attached to this report (Annex 7).
II. Proceedings
An opening speech (see Annex 1) was made by Dr. J.W. Lee, Director of STOP TB, WHO HQ, Geneva, followed by a presentation (Annex 2) on the Global DOTS Expansion Plan by Dr. Mario Raviglione, Chairman of the DOTS Expansion Working Group. After these introductory remarks on the progress of DOTS implementation globally, NTP managers presented their plans, progress, constraints, and financial needs/gaps in the form of posters that were subsequently summarized (Annex 3) by 5 facilitators. Two example countries (i.e. Uganda and Cambodia) presented their successes at increasing case detection through community-based TB programmes and the use of peripheral health facilities for TB control activities. The six WHO regional advisors on TB control presented their regional plans, followed by presentations (Annex 4) on the initiatives of the TB Coalition for Technical Assistance (TBCTA), the Canadian International Development Agency (CIDA), No TB Baltic, the International Paediatric Association (IPA), and on the structure and function of the Stop TB Partnership. A summary (Annex 5) of the DOTS Expansion Working Group Plan was presented by the WHO secretariat. Conclusions (Annex 6) were presented by the meeting raporteur, including future actions to be undertaken by countries, technical partners, financial partners, and the WHO secretariat before the 3rd meeting of the DOTS expansion working group to be held in Montreal, Quebec, Canada in October 2002.
III. Summaries of presentations
The contents of the above mentioned annexes are summarized below:
A. Global DOTS Expansion Plan
The Global DOTS Expansion Plan (GDEP) is a mid-term global strategic plan for accelerating expansion of DOTS. The aim of the plan is to facilitate progress towards achievement of global TB control targets through coordinated global planning, mobilization of resources, and partnership development. The initial focus of the GDEP has been on the 22 high burden countries, though other countries are being incorporated into regional plans.
At the country level, the GDEP includes the following elements:
• development of a 5-year National Strategic Plan for DOTS expansion
• development of an annual implementation plan for each country
• creation of a National Interagency Coordinating Committee
• identification of a main technical collaborator for each of the HBCs, plus identification of other technical and financial partners
• estimation of financial needs and gaps
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At the international level, the GDEP includes the following elements:
• development of 5-year strategic plans and annual implementation plans, including a description of international technical support to be provided by partner agencies
• development of regional plans and Regional Interagency Coordinating Committees
• Estimation of financial needs and gaps for global TB control
The following objectives, reaffirmed at the Paris meeting, are part of the GDEP:
By the end of 2001:
• identify which partners will fill existing technical and financial gaps in each country, and determine budgets required for technical assistance
• develop strategies to facilitate expansion of DOTS beyond the 22 HBC By the end of 2002:
• 35% of all infectious cases will be detected under DOTS
• all HBC will have a functioning National Interagency Coordinating Committee
• WHO will develop a policy for community involvement in TB control
• By the end of 2002, and yearly after that until the TB control targets are reached, WHO (with input from the DEWG, NTP managers, and partners) will update the GDEP to reflect the most current objectives and strategies for expanding DOTS globally. The updated GDEP will be distributed at the 3rd DOTS Expansion Working Group meeting in Montreal, Quebec, Canada to be held in October, 2002
By the end of 2004:
• WHO will develop a policy for involvement of private practitioners in TB control By the end of 2005:
• 70% of all infectious cases will be detected under DOTS, and 85% of those cases will be successfully treated
B. Regional planning
All regions made considerable progress in planning efforts aimed at expanding DOTS. WPRO lead this progress in the previous year (2000) by developing the first medium-term regional strategic plan for 2001-2005. During 2001, all other regional offices prepared such plans which include steps to expand regional capacity and involve partners. The strategic plans also outline activities that will be undertaken by WHO and partners to assist both HBC and other countries in each region in their efforts to expand DOTS. As part of the GDEP, regional meetings of the technical and financial partners were held in the WHO regions of Africa, the Americas, Europe, and the Western Pacific. During these regional meetings, plans were presented to the partners, and decisions were made about how partners can best assist countries with DOTS expansion activities.
Regional Interagency Coordinating Committees (RICC) were formed, and are operating, in 5 of the 6 WHO regions. A RICC in the South-east Asia region is not yet established.
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C. Country planning
1. Development of national plans
During the 1st DOTS Expansion Working Group meeting in Cairo in 2000, it was determined that one of the objectives for 2001 was for each of the 22 HBC to develop a 5-year strategic plan. Of the 22 HBC, all but six countries have completed a plan for DOTS expansion that will guide TB control efforts for the next 3-5 years from 2001- 2005. Six of the countries (i.e. Afghanistan, China, Mozambique, the Russian Federation, Thailand, and Zimbabwe) are still developing plans, or have complete plans that are not yet available to WHO. All 22 countries will have finished the planning process before the end of 2002, and those plans will then be made available to the secretariat of the working group.
2. Estimation of national financial needs and gaps
Budgets for some or all of the years 2002-5 are available for 17 of the 22 HBC.
Budgets are in the process of being developed for the remaining 5 countries, including the Russian Federation, South Africa, Mozambique, and Zimbabwe; a budget is reported to be available for Thailand. For the Russian Federation and Thailand, other recent data are currently being used to provide an indication of the likely budget required.
3. Development of partnerships and National Interagency Coordinating Committees The Global DOTS Expansion Plan recommended that all countries identify a lead technical partner and establish a National Interagency Coordinating Committee (NICC). In compliance with this request, all 22 HBC have identified an international lead technical partner, and 11 of the 22 HBC have formed an NICC including Brazil, Cambodia, China, Kenya, Myanmar, Pakistan, Philippines, Russia, Tanzania, Thailand, and Vietnam). The remaining 11 countries are working to develop NICCs, and these should be operational by the end of 2002.
4. DOTS expansion constraints and opportunities
Information obtained from the poster presentations given during the Paris meeting identified several constraints to DOTS expansion. The most commonly identified constraints were a paucity of resources, a lack of qualified staff, a lack of management skills, and weak laboratory networks. In countries with a high prevalence of HIV, the absence of collaboration between the HIV and TB programmes is a major constraint to the detection and management of TB (and AIDS) cases. The low access to health care services particularly in Ethiopia and Mozambique, but also in parts of other countries, is a serious obstacle to achieving countrywide DOTS coverage. The private health care sector is unregulated in most countries, and commonly does not comply with DOTS standards, though there are exceptions in parts of India, Indonesia, and the Philippines.
Health sector reform, especially the decentralization of TB control activities, was identified as a constraint in Indonesia and the Philippines because district and provincial governments have been reluctant to participate in, and fund, TB control. By contrast, reform has been seen as an opportunity in Cambodia, Ethiopia, and Kenya, where there is now the potential for better access to DOTS services. Other countries did not experience major changes in the organization of their health systems during the period under review, but those with systems that were already decentralized have
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found it hard to expand DOTS quickly because of the time needed to convince local authorities to participate in DOTS.
The war in Afghanistan nearly destroyed the health infrastructure, and the newly- developed DOTS programme was severely curtailed. Similarly in DR Congo, DOTS cannot be expanded into areas affected by war or civil unrest.
To help alleviate drug shortages, the Global Drug Facility supplied three countries (DR Congo, Kenya, Myanmar) in 2001, and placed orders for three additional countries (Pakistan, Uganda, Nigeria) to be delivered in the first quarter of 2002. All HBC have a secure supply of TB drugs for 2002. With the exception of parts of China, drugs will be supplied free of charge to all patients.
`
For each constraint identified, most national TB control programmes have begun to implement activities to overcome them, generally through training, advocacy, and establishment of a laboratory network. Major steps have been taken by India and China to institutionalise TB control in the government system by obtaining either a government resolution (India), or by having the national plan for TB control endorsed by the government (China).
D. Achievements and plans of the DOTS Expansion Working Group
The DOTS Expansion Working Group (DEWG), organized and coordinated by the WHO secretariat, meets yearly to collectively agree on a framework to plan, expand, and sustain support for global tuberculosis control efforts. The working group also advises international technical agencies on how to assist member states in planning for DOTS expansion, monitors and evaluates global progress in DOTS expansion, and identifies and mobilises resources for DOTS expansion.
The DEWG will ensure that the following objectives are met by 2005 in all countries:
• The DOTS strategy is implemented and sustained
• TB control efforts are included in, and contribute to, poverty reduction strategies
• Community-based TB control is implemented, where appropriate
• The private medical sector, and other health and social welfare sectors, contribute to TB control so as to achieve a multi-faceted approach to disease control
In 2001, the DEWG contributed, either directly or indirectly, to the following achievements in TB control:
• Drugs were secured in all DOTS areas of the HBCs
• Additional funding from a variety of sources was secured in 17 HBC
• Planning assistance was provided to the 22 HBCs
• Assistance with the development of cost estimates was provided to the 22 HBCs In 2002, the DEWG will assist with global TB control efforts in the following ways:
• Members of the DEWG will meet with Regional Interagency Coordinating Committees to discuss and plan TB control activities
• Facilitate monitoring and planning for TB control by providing input on the objectives, strategies, and tasks of the GDEP
• Hold the 3rd annual meeting, to take place in Montreal, Canada in October 2002
• Produce report entitled “Global Tuberculosis Control, WHO Report 2002”
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E. Presentations by Partners and and Stop TB Secretariat
The following groups presented their initiatives to assist in global TB control efforts:
• Global Partnership to Stop TB: This partnership of committed TB leaders was launched in November of 1998 and now has 120 partner organizations and is still growing. The partnership’s mission is four-fold, and is directed at ensuring that every TB patient has access to effective diagnosis, treatment, and cure; at stopping transmission of TB; at reducing the inequitable social and economic toll of TB, and at developing and implementing new preventive, diagnostic, and therapeutic tools and strategies to stop TB. During the last year, the partners have contributed in a number of ways to several initiatives all aimed at creating a TB-free world, including the Global DOTS Expansion Plan, the Global TB Drug Facility, the Global Alliance for TB Drug Development, the and the Global Fund to Fight AIDS, TB, and Malaria.
• Tuberculosis Coalition for Technical Assistance: This coalition is comprised of several 6 leading groups in the fight against TB: the American Lung Association, the American Thoracic Society, the U.S. Centers for Disease Control and Prevention; the International Union Against Tuberculosis and Lung Disease, the Royal Netherlands Tuberculosis Association, and the World Health Organization.
Through assessment visits, country assistance, training, regional meetings, advocacy, and other activities, the TBCTA aims to improve and expand the capacity of USAID to respond to the Global TB epidemic, while simultaneously complementing existing global TB control efforts such as the GDEP, the Stop TB Initiative, and the activities of the individual TBCTA partners. During 2001, the TBCTA held meetings and trainings (and contributed funding to these activities), published an information bulletin, and visited several high burden and other countries.
• International Paediatric Association: This organization represents 500,000 paediatricians and paediatric groups from 150 countries on the issues of child health. The IPA has formed an international IPA committee on childhood tuberculosis and is now a partner in the WHO Stop TB campaign. During 2002, the IPA plans to convene 2 regional meetings of TB experts (in Kenya and China) to present issues of childhood TB, to discuss how childhood TB can be brought into national TB programmes on a country level, and to ultimately develop a joint IPA/WHO policy statement on childhood TB along with a manual on its the management. Additionally, IPA is working with the National Institutes of Health in the U.S. on planning a conference to establish an international research agency for paediatric TB.
• No-TB-Baltic (Nordic-Baltic Tuberculosis Project): The project is a collaboration between Baltic and Nordic partners with the objective of providing technical and financial support to consolidate the DOTS strategy countrywide in Estonia, Latvia, and Lithuania. However, support from this project is ending at the beginning of 2002.
IV. Progress in global TB control
The encouraging news about DOTS expansion is that 148 countries had adopted the WHO strategy by the end of 2000; over half the world’s population lived in counties,
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districts, and provinces that provide DOTS; nearly 2 million new TB patients were notified under DOTS in 2000, over one million of them smear-positive; and treatment had a successful outcome for 80% of registered patients.
A more arresting observation is that the rate of progress in case finding has not changed since 1994. NTPs around the world have been enrolling an average of
130 000 extra smear-positive cases each year, at which rate the target of 70% case detection will not be reached until 2013. Another concern is that the smear-positive case detection rate under DOTS (27%) appears to be levelling off at 35-40%. Since 1994 (when WHO record-keeping began), NTPs have never notified, from all sources, more than 40% of the estimated smear-positive cases, and DOTS programmes have mostly recruited cases that would previously have been notified under non-DOTS schemes, rather than finding additional smear-positive cases. Therefore, to reach the case detection target by 2005, about 330 000 additional smear-positive cases must be recruited globally each year under DOTS, including a substantial fraction of the 60%
of new cases that are not notified each year to WHO.
Among the 22 HBC, the greatest strides in case finding under DOTS were made in India, the Philippines, Ethiopia, South Africa, and Myanmar. In the three Asian countries, these improvements almost certainly represent real increases in the proportion of cases detected and cured. It is more doubtful that DOTS programmes in Ethiopia and South Africa have detected larger proportions of cases, because case notifications in these two countries are rising anyway with the spread of HIV/AIDS.
V. Conclusions and proposed actions
The meeting confirmed the tremendous motivation by the international TB control community to achieve the targets set by the WHO Health Assembly for 2005. It also allowed donors to have direct contact with NTP managers and to discuss plans for support. The following ideas for future action were proposed at the meeting, and development of these ideas into achievable actions will ensure that continuing progress is made in the effort to control TB globally.
A. Actions proposed for countries and regions, November 2001-October 2002
• Finalize 5-year country DOTS expansion plans for Afghanistan, China, Mozambique, the Russian Federation, Thailand, and Zimbabwe, and provide WHO with a copy of each plan
• WHO and partners will assist Zimbabwe in developing a DOTS expansion plan
• Complete or refine cost estimate data collection, including financial needs and gaps
• implement financial monitoring system after it is developed by WHO
• Establish fully operational National Interagency Coordinating Committees (NICC) in all 11 countries where they are still under development (i.e. India, Indonesia, Nigeria, Bangladesh, Ethiopia, South Africa, DR Congo, Uganda, Mozambique, Zimbabwe, and Afghanistan)
• implement regular Regional Interagency Coordinating Committee (RICC) meetings
• Systematically assess training needs aimed at improving collaboration and coordination of TB and HIV/AIDS programmes, where relevant
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• Address MDR-TB by developing links with DOTS Plus, the working group, and the Green Light Committee, where relevant
B. Actions proposed for technical partners, November 2001-October 2002
• Further develop task force on training to prepare training materials and assist with coordination of international training
• Train consultants on how to organize and conduct external evaluations of the TB programme
• Develop and provide technical assistance to NTPs enabling them to adapt to decentralisation and other health system changes
• Study different approaches to increasing case detection
• Implement country-specific strategies for involvement of private practitioners
• Identify country-specific areas for technical support and provide support tailored to specific country needs
C. Actions proposed for financial partners, November 2001-October 2002
• Mobilise resources for countries and technical partners to facilitate DOTS expansion
• Support Global Drug Facility
• Support the Global Fund to Fight AIDS, TB, and Malaria D. Actions proposed for WHO, November 2001-October 2002
• Ensure coordination and provide guidance where appropriate
• In partnership with NTP managers and other partners, prepare cost estimates for all high incidence countries and determine financial gap
• Design and implement global financial monitoring project
• Refine and revise GDEP to reflect most recent developments in planning for global DOTS expansion
• Promote DGEP as a template to absorb new resources from Global fund
• Establish regular RICC meetings
• Continue to serve as coordinating agency for the DEWG, including the preparation of reports and plans
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SECOND MEETING OF THE STOP TB
DOTS EXPANSION WORKING GROUP PARIS,31OCTOBER 2001
Last week, 200 persons including representatives of 18 of the highest TB burden countries, gathered at the World Bank Headquarters in Washington for the first Stop TB Partners’
Forum to discuss progress made since Amsterdam and to review the Global plan to Stop TB.
As you recall, the Ministerial Conference on Tuberculosis & Sustainable Development held on 24 March 2000 in Amsterdam adopted the Amsterdam Declaration to STOP TB.
Ministers of Health and Finances of the 20 high-burden countries, comprising 80% of the global TB burden, called for rapid DOTS expansion.
Following the Amsterdam Conference, WHO, on behalf of the StopTB Partnership, convened the first “International Workshop to Accelerate DOTS Expansion” in Cairo on 22- 23 November 2000. During that meeting, the “DOTS Expansion Working Group” was formally established under the aegis of the Stop TB Initiative. During that workshop, the national TB programme managers of the 22 high burden countries, the technical partners, the financial partners and the global network of WHO agreed to develop a Global DOTS Expansion Plan (GDEP).
As agreed at the first meeting of the Working Group in Cairo, the two pillars of the GDEP are: (1) the development of and commitment to national DOTS Expansion plans; and (2) partnership-building to implement the plan. All DOTS expansion plans to achieve targets by 2005 must be technically sound and feasible for implementation, and take into account the characteristics of the national health system. These plans should identify the major inputs and budget required for DOTS expansion. The participants to the workshop agreed that, by the end of 2001, all high burden countries will have developed such plans.
To facilitate this process, partnership is crucial and must be built among countries, agencies, foundations and non-governmental organizations, respecting and reinforcing the sovereignty of countries for the health of their people. We will hear today where we stand in terms of planning, implementing and financing for all of the 22 priority countries.
The global Stop TB Partners’ Forum of last week highlighted the progress made since Amsterdam and the tasks remaining to be addressed to control tuberculosis, considering all the aspects in a newly established Global Plan to Stop TB. The urgent top priority task to undertake is DOTS expansion that will allow to achieve the global targets of 70% case detection while maintaining 85% cure rate in 2005. This is key to control the disease. The Global Drug Facility, which is an integral part of the DOTS expansion plan, has been
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established to increase access to quality drugs, and serves as an enabler and strong stimulus for DOTS expansion in some countries.
We are learning that some TB high burden countries are already making great strides in DOTS expansion: Peru, with its singular success in "graduating out" of the high burden category through a potent mix of strong political commitment, patient support, incentives and education; India, with its remarkably rapid and effective DOTS expansion covering now 410 million people; Uganda, with its model of community-based care; Kenya, with the involvement of the private sector; Cambodia, with its increase in case detection using the most peripheral health facilities.
Let us look briefly at the objectives of this meeting, the second of the DOTS expansion working group. We aim to:
1. review progress in DOTS expansion made in countries since the Cairo 2000 meeting;
2. agree on priority activities to be implemented in 2002;
3. identify human and financial resources needed to implement activities;
4. define needs and funding gaps of technical agencies that are committed to support countries
If we succeed in achieving our objectives, we will be better placed to reach the global targets.
In fact, we need to accelerate our pace. The next 50 months (between October 2001 and December 2005) are crucial. In comparison to the past 50 years, these 50 months bring us to the time for a “count down call to action” to achieve global TB detection and cure targets.
We know what must be done and we know how much it will cost.
Thus, let us act now and build on the Washington Commitment which call national governments and partners to accomplish the following, among others:
• Within the next 50 days (end of 2001)
- All high burden countries will finalize national plans to achieve the global targets for TB control
• Within the next 50 weeks (end of 2002) - DOTS case detection rate will reach 35%
- All high burden countries will establish interagency coordinating committees, or similar mechanisms, that will include tuberculosis control within the scope of their mandates;
- The global TB drug facility will provide drugs to treat at least one million additional patients.
• Within the next 50 months (end of 2005)
- DOTS case detection rate will reach 70% whilst maintaining a treatment success rate of at least 85%
- Effective response to TB/HIV and to multidrug resistant TB will be scaled up
These are ambitious targets that will not be achieved without the full commitment of the endemic countries. However, the current environment in TB control is unique in its fresh
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enthusiasm and this opportunity cannot be missed. Partners are willing to support progress, both technically and financially, countries are willing to commit and take the challenge, and plans and costing assessments have been prepared. It is now a matter of intensive implementation.
The DOTS Expansion Working Group of the Stop TB Partnership is central to TB control in the world.
I am sure the analysis of progress will demonstrate how much has been delivered during the last 12 months. It is up to us all, now, to keep the momentum created and to intensify further our efforts towards better TB control in the world.
Global DOTS Expansion Plan Global DOTS Expansion Plan
Concept and Progress Concept and Progress
Mario C. Raviglione Mario C. Raviglione
Stop TB Stop TB
Communicable Diseases Communicable Diseases
Second DOTS Expansion Working Group Meeting 31 October 2001
Paris, France
Projected DOTS case detection Projected DOTS case detection
Without accelerated expansion, World Health Without accelerated expansion, World Health
Assembly targets cannot be reached by 2005 Assembly targets cannot be reached by 2005
0 10 20 30 40 50 60 70 80
1990 1995 2000 2005 2010 2015 Year
Cases notified under DOTS (%)
average rate of progress:
target 2013 accelerated progress:
target 2005 WHO target 70%
DOTS begins 1991
Background
Amsterdam Ministerial Conference, March 2000
attended by 20 of top 22 high-burden countries (≈ 80% of global cases)
commitment to expand DOTS to detect 70% of SS+ cases by 2005
Following Amsterdam:
WHA 2000: HBC request WHO assistance
International partners express readiness to contribute as part of strategic, co-ordinated plan
Development of GDEP in Cairo
11/2000 and launch at WHA in 5/2001
Partners Forum in Washington,
10/2001, promoted GDEP in GPSTB
What is the GDEP?
A mid-term global strategic plan for accelerated expansion of DOTS
the aim of which is to:
• accelerate progress towards achievement of global TB control targets through:
– co-ordinated global planning + mobilisation of resources
– emphasis on partnerships
Initial focus on the 22 “High-Burden” Countries
What is the GDEP? (cont.)
At country level:
5-Year National Strategic Plan for DOTS Expansion
Annual implementation plan
A Coalition Government - Partners (N-ICC)
Main Technical Collaborator
Other Technical and Financial Partners identified
Estimated Financial Needs and Gaps
At international level:
5-year and annual plan of international technical
support by partner agencies
Regional plans and coalitions (R-ICC)
Estimated financial needs
and gaps
GDEP: situation now
(31 October 2001)
• Status of 5-year plans, national & regional
• Status of national partnerships
• Status of national and regional interagency committees (N-ICC & R-ICC)
• Status of financial assessments
Mid Mid - - term planning status in 22 high term planning status in 22 high - - burden burden countries
countries - - Late 2001 Late 2001
14 : Complete Plans:
Bangladesh, Cambodia, DR Congo, Ethiopia, Kenya,
Indonesia, Myanmar, Pakistan, Philippines, South Africa, UR Tanzania, Uganda, Vietnam (Peru)
1 : No Plans
7 : Plans under development or
incomplete (in years or geographical
coverage)
Status of 5
Status of 5 - - year country plans year country plans for 22 HBC
for 22 HBC
Sound plan Sound plan prior to Cairo prior to Cairo
meeting meeting
No plan No plan Plan under
Plan under development development or incomplete or incomplete New or
New or improved improved plan since plan since
Cairo Cairo meeting meeting Cambodia
Ethiopia Kenya Peru
Tanzania Vietnam
Bangladesh DR Congo Indonesia Myanmar Pakistan Philippines South Africa Uganda
Afghanistan Brazil
China India Nigeria
Russian Fed Thailand
Zimbabwe
Status of regional strategic plans Status of regional strategic plans
Sound plan Sound plan prior to Cairo prior to Cairo
meeting meeting
Plan Plan under under development development New or
New or improved improved plan since plan since
Cairo Cairo meeting meeting
WPRO AFRO
AMRO EURO
SEARO
EMRO
Technical & financial partners Technical & financial partners
identified for all 22 countries identified for all 22 countries
Russia: WHO USAID, CDC, DFID, FLA GTZ, NLHA, PIH, OSI, WB
Cambodia: JICA, WHO JATA/RIT, WB, USAID China: WHO KNCV, DFID, IUATLD, WB
Philippines: WHO JICA, KNCV, CDC, CIDA, USAID, WB Vietnam: KNCV WHO, CDC, NL, WB
Bangladesh: WHO USAID, WB
India: WHO DFID, DANIDA, CIDA, USAID, WB
Indonesia: KNCV WHO, AUSAID, NL, ?WB Myanmar: IUATLD/WHO UNDP
Thailand: WHO IUATLD
Ethiopia: KNCV/WHO WHO, NL, GLRA, IUATLD, WB DR Congo: IUATLD/DFB WHO
Kenya: KNCV WHO, NL, CDC, WB
Nigeria: WHO/IUATLDGLRA, DFB, NLR, WB
S. Africa: IUATLD/WHODFID, CDC, USAID, BEL, ?WB Tanzania: KNCV WHO, IUATLD, GLRA, SWISS, WB Uganda: WHO/IUATLDGLRA, LMI, ICD, DFID, WB
Zimbabwe: IUATLD/WHONL, DANIDA, ?WB Brazil: WHO/IUATLDGLRA, DFB,
USAID
Peru: WHO PIH, IUATLD, CDC, WB
i
Afghanistan; WHO ICD, NOR Pakistan: WHO/IUATLD KNCV, WB
GLRA, ICD, DFID
Status of establishment of inter Status of establishment of inter - -
agency committees (N
agency committees (N - - ICC) ICC)
22 High-Burden Countries Regions
no
under dev.
not required yes
7 3 2 10
5
1
Estimated annual needs and gaps, 22 HBC plus all other low and lower-middle-
income countries
1159
1327
436
522
0 200 400 600 800 1000 1200 1400
22 HBC 22 HBC plus all other LIC and LMIC
Tot a l a nnua l cos t ( U S$ m illio n s )
Total need
Total gap
Governments of high
Governments of high - - burden countries burden countries
contribute more than half the financial needs contribute more than half the financial needs
22 High-Burden Countries
1159M$
Gap 436M$
Gvt Contribution 689M$
Grants - 10M$
Loans - 24M$
GDEP GDEP - - current priorities, late current priorities, late - - 2001 2001
Plans for all 22 HBC to be ready after this meeting
Finalize immediately after the meeting:
detailed plan for the next year identifying which partners will fill existing technical and financial gaps
budget required for technical assistance (in addition to what is currently in plans)
Facilitation of expansion of DOTS beyond 22 HBC
through WHO and partners’ regional strategic plans
Outcomes for achieving the 2005 Outcomes for achieving the 2005
targets targets
25 million lives saved by 2020
55 million cases averted by 2020
Progress in TB Control, Progress in TB Control,
high high - - burden Countries, 1998 burden Countries, 1998 - - 99 99
30 40 50 60 70 80 90 100
0 10 20 30 40 50 60 70 80 90 100
DOTS detection rate (%)
Treatment success (%)
Uganda DRCongo
Kenya Tanzania
Peru Vietnam
Myanmar Bangladesh
India
Philippines
Indonesia
China
Ethiopia Nigeria
Russia
South Africa
Thailand
Cambodia
Pakistan
Afghanistan Brazil
Zimbabwe
DOTS is expanding rapidly in India DOTS is expanding rapidly in India
1998 1998 - - 2001 2001
410 million
210 million 130 million
18 million
July 1998 July 1999 July 2000 May 2001
40% of the population now has access to the RNTCP
TB deaths prevented every year in TB deaths prevented every year in
China through DOTS Expansion China through DOTS Expansion
0 10 20 30 40 50 60
case fatality (-programme)
case fatality (+programme)
deaths averted
percentage
30 000
DOTS results in TB incidence decline DOTS results in TB incidence decline
The case of Peru The case of Peru
100 120 140 160 180 200 220
1980 1985 1990 1995 2000
Pulmonary TB cases/100,000
DOTS 1990
PTB falling at 6%/yr
case finding
GDEP targets to be achieved GDEP targets to be achieved
End 2001 : all HBC will have a 5-year plan and all WHO ROs will have a medium-term plan for DOTS expansion
End 2002 : 35% of all infectious cases detected under DOTS and all HBC will have a defined N-ICC
End 2005 : 70% of all infectious cases detected under DOTS and 85% treated successfully
Plus by end 2002, WHO policy for community involvement in TB
control and, by end 2004, WHO policy for involvement of private
practitioners in TB control
Next steps:
Next steps:
Endemic countries: finalize plans and budgets, establish N-ICC and commit to expansion
Technical agencies: assist endemic countries and define financial needs and gaps
Financial partners: mobilize resources for GDEP and GDF as integral parts of GPSTB
WHO: ensure coordination, start global financial
monitoring, promote GDEP as a template to absorb
new resources from Global Fund
Plenary Session: summary of poster presentations
For the purpose of analysing the 22 poster presentations, the countries were divided into 5 groups as shown below. A summary of the issues collectively or individually faced by these countries accompanies each grouping.
GROUP 1: Sustaining DOTS and reaching beyond DOTS
These countries have achieved, or are close to achieving, the global targets for DOTS, but are challenged to sustain and reach beyond DOTS. The countries in this group are Cambodia, Kenya, Peru, Tanzania, Uganda, and Viet Nam.
Challenges:
• Health sector reform environment
• Financing constraints
• Staff constraints
• Coordination with TB/HIV response
• Private sector involvement
• Community involvement Main needs:
• financing from the Ministries of Health
• technical analysis from the National TB Programme
• wider policy support from government levels Main Strategies:
• Build human resources
• Position TB in health sector reform
• Expand partnerships
• Build demand via information, education, and communication
• Address TB/HIV
• Expand DOTS and redefine coverage (e.g. urban, prisons, districts) GROUP 2: Challenge to achieve country-wide DOTS coverage
Although these countries have a good quality DOTS programme, their challenge is that they have not yet achieved the global targets. The countries in this group are Bangladesh, China, DR Congo, and India.
Challenges:
• Involvement of private sectors, hospitals, NGOs, medical colleges
• Funding gaps, especially for TB drugs and training
• Human resource development including training, staff retention, management capacity
• Supervision of programme, including an adequate monitoring system and adequate staff
• Quality of drugs and laboratory network (and quality control system)
• TB/HIV co-epidemic, including coordination between the two programmess
• Balancing rapid expansion with maintenance of programme quality
• Large populations, geographical areas, and poor primary health care infrastructure especially in India and China
GROUP 3: Challenge to sustain quality DOTS
These countries have implemented DOTS but are challenged, for a variety of reasons, to sustain the quality of their programmess. The countries in this group are
Afghanistan, Ethiopia, Myanmar, Philippines, and Zimbabwe.
Challenges:
• Limited accessibility and health infrastructure resulting in low DOTS coverage
• High TB burden due to HIV resulting in high workload for health service workers, especially in African countries
• Important role of private sector, especially in Asian countries
• Decentralization resulting in funding gaps for implementing DOTS expansion plans, especially at local government level
Main Strategies:
• Community development to overcome challenges of accessibility and HIV epidemic
• Public/private partnerships
• Strengthen supervision and monitoring, especially for DOTS recording and reporting
• Resource mobilization of local government, national government, and external partners, and the establishment of national interagency coordinating committees
GROUP 4: Challenge to build commitment to DOTS
These countries have not yet achieved DOTS because of challenges in securing political commitment across all necessary levels of government. The countries in this group are Brazil, Russian Federation, and South Africa.
Challenges:
• Roll-out DOTS to state/provincial/district levels
• Sustain initial commitment and achievements
• Finding ways to effectively strengthen NTP staff and management
• Better coordination of technical agencies
• underfunding as a result of growth and decentralization
• MDR-TB in Russia Main needs:
• TB/HIV coordination for Brazil and South Africa
• New health care system for Russia
• Obtain technical assistance for monitoring, capacity building, and operational research
GROUP 5: Expansion of quality DOTS
These countries face challenges to expand the quality of their DOTS programmess.
The countries in this group are Indonesia, Nigeria, Pakistan, and Thailand
Challenges:
• Complications from decentralization
• Lack of funding and planning
• Insufficient capacity building
TBCTA
TUBERCULOSIS COALITION FOR TECHNICAL ASSISTANCE
Jaap F. Broekmans, MD, MPH Director KNCV
Chairperson Board TBCTA
Paris, October 31, 2001
TBCTA
Purpose
1. Improve and expand the capacity of USAID to respond to the Global TB epidemic;
2. Complement and enlarge upon existing global TB control efforts, such as the
Global DOTS Expansion Plan, the Stop TB
Initiative and the activities of the individual
TBCTA partners.
TBCTA
How
Providing state-of-the-art, context
appropriate, technically sound and cost- effective consultation and technical
assistance.
Where
High burden countries and countries with
USAID missions.
TBCTA
Goal
To reduce the global burden of TB and its attendant mortality, thus significantly
improving human health, well being and
development particularly among the poor.
TBCTA
Partners
• American Lung Association (ALA);
• American Thoracic Society (ATS);
• Centers for Disease Control and Prevention (CDC);
• International Union Against Tuberculosis and Lung Disease (IUATLD);
• Royal Netherlands Tuberculosis Association (KNCV);
• World Health Organization (WHO).
TBCTA
Activities
1. Assessment visits 2. Country assistance 3. Training
4. Regional meetings
5. Other activities
TBCTA
Activities 3. Training
• Task Force Training
• International training courses
• National training courses
• Training courses consultants
• Training USAID staff
TBCTA
Activities
5. Other activities
• In-country meetings
• Operations research projects
• Drug resistance surveys
• Drug quality control
• IEC materials
• Information bulletins
TBCTA
Organization
• Board of Directors
• Project Management Unit Coordination
• Among partners
• With USAID Global, Geographic and Field
• Public and private partners in target
countries
TBCTA
Implemented activities Year 1
• Staffing PMU
• Sub-contracts (in final stage)
• Board meetings
• Information Bulletin
• Task Force Training
• Task Force Advocacy (programmed)
TBCTA
Implemented Activities Year 1 (continued )
• Visits to high burden countries: Brazil,
Cambodia, Congo DR, Ethiopia, Indonesia, Kenya, South Africa and Uganda.
• Visits to other countries: Dominican Republic, Haiti, Malawi, Senegal.
• Programmed visits to India, Philippines, Russia, El Salvador, Kazakhstan,
Kyrgyzstan, Uzbekistan.
TBCTA
Implemented Activities Year 1 (continued )
• International courses (Arusha, Hanoi, Managua, Operations Reseach and Int.
Resp. Epidemiology course).
• Funding of participation in NAR meeting, Wolfheze Conference, Partners Forum,
Global DOTS Expansion Working Group.
• TB-HIV Working group Stop TB
Partnership.
DOTS Expansion DOTS Expansion Working Group plan Working Group plan
Leopold Blanc Leopold Blanc TBS, Stop TB TBS, Stop TB
Communicable Diseases Communicable Diseases
Second DOTS Expansion Working Group Meeting 31 October 2001
Paris, France
Background
Following Amsterdam:
WHA 2000: HBC request WHO assistance
International partners express readiness to contribute as part of strategic, co-ordinated plan
Development of GDEP Cairo November 2000
22 HBC to develop 5 year plans
6 WHO regions strategic plans
Identification of financial requirements
Establishment of Stop TB DOTS
Expansion Working Group
Purpose of the DEWG
• To agree on a framework to plan, expand and sustain support to tuberculosis control efforts
• To advise international technical agencies on how to assist Member States in planning DOTS expansion and establish partnership
• To monitor and evaluate progress in DOTS expansion
• To identify and mobilise resources for DOTS
expansion.
Objectives of the DEWG
Ensure that by 2005 in all countries
• comprehensive TB control using DOTS strategy is implemented and sustained
• TB control efforts are included in and contribute to health sector and poverty reduction strategy
• community is involved in the control of TB
• private medical sector and other sector contribute in
TB control
Targets of the DEWG
2005 70%
85%
all countries all countries all countries all personnel
all countries DOTS areas 2003 2003
50%
85%
all regional all HBC all countries DOTS areas
all HBC DOTS areas 2001 2001
35%
85%
22 HBC 10 HBC 22 HBC DOTS areas
11 HBC DOTS areas Targets
Targets DOTS expansion - detection
- treatment Govt commit.
- TB control policy - Human/financial Planning
- National DEP
- Capacity DOTS
Implementation
- Ref laboratory
- Drug proc/distrib
Targets of the DEWG
2005
all countries all HBC all countries all countries most HIncC few countries 2003 2003
all countries 10 HBC
all HBC all HBC all HBC
Pilot 2001 2001
all HBC 5 HBC 10 HBC 10 HBC 10 HBC
Pilot Targets
Targets Monit./surv.
- WHO indicators - DRS established HS development
-TB as performance - PP/community
Op Research
- National capacity
- Integrated care
Achievements: Mid
Achievements: Mid - - term planning status in 22 term planning status in 22 high high - - burden countries burden countries - - Late 2001 Late 2001
14 : Complete Plans
1 : No Plans
Zimbabwe
7 : Plans under development
Nigeria, Brazil, Afghanistan,
Russian federation, India,
Thailand China
Achievements Achievements
Drugs:
secured in 15 HBC (2 with GDF: Myanmar and Kenya)
uncertain drug supply in 7 countries:
- 2 with uncertainty: Mozambique and Zimbabwe
- China: drug supply following DOTS expansion
- 4 with pending application to GDF: Bangladesh, DR Congo, Nigeria, Pakistan
Funding:
Documented additional funding in 17 HBC
- including pledges that will be implemented in 2002
- national additional funding : China, Philippines, Kenya…..
Technical & financial partners Technical & financial partners
identified for all 22 countries identified for all 22 countries
Russia: WHO USAID, CDC, DFID GTZ, PIH, OSI, WB
Cambodia: JICA, WHO JATA/RIT, WB, USAID China: WHO KNCV, DFID, IUATLD, WB
Philippines: WHO JICA, KNCV, CDC, CIDA, USAID, WB Vietnam: KNCV WHO, CDC, NL, WB
Bangladesh: WHO USAID, WB
India: WHO DFID, DANIDA, CIDA, USAID, WB
Indonesia: KNCV/ WHO, AUSAID, NL, ?WB Myanmar: IUATLD/WHO UNDP
Thailand: WHO Ethiopia: KNCV/WHO WHO, NL, GLRA, IUATLD, WB
DR Congo: IUATLD DFB, WHO
Kenya: KNCV WHO, NL, CDC, WB
Nigeria: WHO/IUATLDGLRA, DFB, NLR, WB
S. Africa: IUATLD/WHODFID, CDC, USAID, BEL, ?WB Tanzania: KNCV WHO, IUATLD, GLRA, SWISS, WB Uganda: WHO/IUATLDGLRA, LMI, ICD, DFID, WB
Zimbabwe: WHO NL, DANIDA
Brazil: WHO/IUATLDGLRA, DFB, USAID
Peru: WHO PIH, IUATLD, CDC, WB
i
Afghanistan; WHO ICD, NOR, GLRA, MEDAIR Pakistan: WHO/IUATLD GLRA, WB, DFID, ICD
