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USAID Portfolio Review: Tuberculosis

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Title: USAID Portfolio Review: Tuberculosis


1
USAID Portfolio Review Tuberculosis
DRAFT
January 14, 2011
2
Contents and executive summary
  • Background
  • Epidemiology fighting disease in three groups
    general population, HIV-affected, MDR-TB
  • Fight against TB is well coordinated globally
    across a number of different actors, among which
    USG plays a leading role
  • USAIDs strategic approach
  • USG context means important legal and policy
    requirements and a Whole of Govt approach
  • By area, gt 90 of USAID resources spent on
    country-level activity
  • By activity, 75 of funding supports service
    delivery, 11 ME/HSS, 9 research
  • Solid gains made in many areas e.g. HIV patients
    tested for TB but large numbers of people still
    unreached
  • Challenges/areas of improvement and how we are
    working to resolve them
  • Scenarios help us work through funding
    uncertainties and constraints
  • Working closely with Global Fund to address its
    constraints
  • Scaling up priority areas of MDR-TB treatment,
    HIV/TB diagnosis and treatment, private sector
    engagement and new technologies
  • Wrap-up considerations

3
Tuberculosis epidemiology incidence rates, 2009
Per 100,000 population
  • 9.4 million cases, 1.7 million deaths annually
  • 22 countries account for 80 of global burden
  • Primarily affects most economically productive
    age group (18-40)
  • Social determinants linked to poverty
  • Gender variation in epidemiology across countries

4
Estimated HIV prevalence in new TB cases, 2009
x
x
5
Absolute numbers of estimated cases with MDR-TB
09 1099 100999 10009 999 gt10 000 No estimate
  • 25 high MDR-burden countries
  • 55 in China India Russian Federation

6
Global reductions in TB incidence, prevalence and
mortality
Rates per 100,000 population
Much progress to date but targets not yet achieved
Blue band confidence interval
7
The framework of the global Stop TB Strategy
8
Scale of the Global Plan to Stop TB
Planned budget 2011-2015
Plan component US billions total
IMPLEMENTATION 36.9 79
DOTS 22.6 48
MDR-TB 7.1 15
TB/HIV 2.8 6
Lab strengthening 4.0 8
TA 0.4 1
RD 9.8 21
TOTAL 46.7 100
  • Currently 21 billion funding gap to 2015
  • USG investments in TB are critical to meeting
    these financing gaps

9
Contents and executive summary
  • Background
  • Epidemiology fighting disease in three groups
    general population, HIV-affected, MDR-TB
  • Fight against TB is well coordinated globally
    across a number of different actors, among which
    USG plays a leading role
  • USAIDs strategic approach
  • USG context means important legal and policy
    requirements and a Whole of Govt approach
  • By area, gt 90 of USAID resources spent on
    country-level activity
  • By activity, 75 of funding supports service
    delivery, 11 ME/HSS, 9 research
  • Solid gains made in many areas, e.g., HIV
    patients tested for TB, but large numbers of
    people still unreached
  • Challenges/areas of improvement and how we are
    working to resolve them
  • Developing scenarios helps us work through
    funding uncertainties and constraints
  • Working closely with Global Fund to address its
    constraints
  • Scaling up priority areas of MDR-TB treatment,
    HIV/TB diagnosis and treatment, private sector
    engagement and new technologies
  • Wrap-up considerations

10
USG funding for TB has increased steadily
recognizing both the seriousness of the challenge
and USG successes in addressing it
545
478
  • USG present in TB research for many years, but
    extensive experience in implementation only over
    the last few years
  • Moment is right to take stock of results, lessons
    learned, gaps

454
378
298
270
221
196
174
143
96
88
76
67
CDC data to come
11
USG targets embody important legal and policy
frameworks
12
Key approaches for the USG TB strategy
  • Promote country ownership
  • Identify and directly target constraints to
    progress
  • Address key financing gaps and serve as funding
    catalyst
  • Leverage resources
  • Promote success of Global Fund grants
  • Further TB/HIV through PEPFAR
  • Capitalize on other health platforms (nutrition,
    MCH, etc.)
  • Provide global technical leadership
  • Invest in the future new tools and innovation
  • Expand partnerships
  • Stop TB, UNITAID, Global Fund

13
USG TB strategy six key interventions that map
to the GHI principles
The six key TB interventions
  • Accelerate detection and treatment of TB
  • Scale-up prevention and treatment of MDR TB
  • Expand coverage of interventions for TB/HIV
    co-infection
  • Contribute to health system strengthening
  • Address social determinants of TB
  • Promote research and Innovation

14
USAID works through a Federal TB Task Force to
contribute to a coordinated USG TB response
15
Research an example of coordination across the
USG
Pre-clinical trials
Basic science discovery
Clinical trials phase 1-2
Clinical trials phases 2b-3
Field demonstration
Policy practice
Operations research, surveillance evaluation
Test and introduce new approaches
CDC Field preparedness for and implementation of
trials
NIH Stimulating innovation
USAID Informing the research community on field
priorities
USAID Bringing advances to the field
16
USAID is currently working in 40 countries
Category Countries
Focus Countries (20) Afghanistan, Bangladesh, Brazil, Cambodia, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Nigeria, Pakistan, The Philippines, Russia, South Africa, Tanzania, Uganda, Ukraine, Zambia, Zimbabwe
Other Countries (20) Armenia, Azerbaijan, Bolivia, Djibouti, Dominican Republic, Georgia, Ghana, Haiti, Kazakhstan, Kyrgyzstan, Liberia, Malawi, Mexico, Namibia, Peru, Senegal, Southern Sudan, Tajikistan, Turkmenistan, Uzbekistan
  • Countries of greatest need as defined by
  • TB burden
  • TB incidence
  • HIV/AIDS prevalence
  • Prevalence or potential for MDR-TB or XDR-TB
  • Lagging case detection and treatment success
    rates
  • Additionally, the portfolio includes countries
    based on
  • Technical managerial feasibility
  • Political commitment

Underline High TB burden countries MDR TB
Countries
17
Regional and HQ staffing for USAIDs TB
portfolio
  • Europe Eurasia Region
  • 4 USAID TB FTEs
  • 5 other project TB technical FTEs in country

Washington DC 11 HQ FTEs
  • Asia Middle East
  • 6 USAID TB FTEs
  • 10 other project TB technical FTEs in country
  • Latin America/ Caribbean
  • 4 USAID TB FTEs
  • 5 other project TB technical FTEs in country
  • Africa
  • 16 USAID TB FTEs
  • 20 project TB technical FTEs in country

Regional divisions per USAIDs operating
model FTEs accurate as of 4 January 2011
18
USAIDs strategic and operational level
programming
USAID TB expenditures in 2009 ( of total budget)
Governance, finance, strategic information11
  • Almost 75 of funding spent on TB service
    delivery
  • Resource allocations made to address particular
    country strategies and needs
  • Large scale-up over recent years in MDR-TB
    reflects strategic priorities

Source Foreign Assistance and Coordination
Tracking System (FACTS)
19
USAID funding is strategically allocated to help
countries where they need it most
  • In low resource countries, USAID TB programs
    support policy dialogue, technical assistance,
    support for service delivery and Global Fund
    grant implementation
  • In higher resource countries we provide the above
    but limited support for service delivery

20
How we provide support USAID has prioritized
funding to the field with targeted support from HQ
  • Provides for
  • Response to gaps and local needs
  • Partnership with Ministries of Health
  • Collaboration with other donors and partners
  • Global Drug Facility (directive)

Field level gt90 of total funding
  • Provides for
  • Policy development and activities of global /
    regional benefit
  • Research with global implications
  • Technical support to the field for evaluation,
    program design, monitoring, special issues

HQ/ regional bureaus lt 10 of total funding
21
USAID TB Program at the Country Level
  • How we work with countries
  • Access to international technical expertise
    through global and country-level projects
  • Quality-assured laboratories
  • Standardized treatment, patient support and
    supervision
  • Quality drug supply management system
  • ME
  • TB-HIV
  • MDR
  • Community care
  • Partnership with the private sector
  • Support for the Global Fund and other partners

22
Indonesia country example responding to country
priorities and constraints
  • TB program support mainly Government of
    Indonesia (GOI), GF, and USAID
  • Some USAID-funded staff co-located with National
    TB Program
  • Priorities for Ministry translated into USAID
    funding priorities
  • Promoting success of Global Fund resources
  • Launching MDR-TB diagnosis, treatment
  • Ensuring quality TB diagnosis and treatment in
    hospitals and prisons
  • Results
  • National case detection increased from 39 (2002)
    to 80 (2008)
  • USAID able to swiftly reprogram funds to cover
    critical funding needs when GF grant stalled
    (2009)/joint work plan with GF and GOI
  • By end of 2010, 162 MDR-TB patients put on
    treatment with USAID support
  • Pilot hospitals doubled case detection from 2007
    to 2009
  • Expansion to 169 hospitals
  • Referral networks to 65 district health offices
  • Work began in prisons

23
USAID TB Program partners and activities at
Headquarters
Key partners and mechanisms
Examples of activities and outputs
Text
  • WHO technical leadership, normative functions
    and technical assistance
  • CDC operational research, infection control, MDR
    surveillance, laboratory activities
  • TREAT TB research
  • Strengthening Pharmaceutical Systems, U.S.
    Pharmacopeia supply chain management, drug
    quality assurance project
  • Stop TB Partnership, including GDF
  • TB CARE I and II, TB Task Order projects that
    implement STOP TB Strategy
  • International Standards of TB Care
  • Lab Toolbox
  • Planning and Budgeting Tool
  • Public-Private Mix Toolkit
  • Electronic TB Register
  • Guide for Quality Diagnosis and Role of X-Ray
  • Patient-Centered Approach Package
  • Guiding Principles and Practical Steps For
    Engaging Hospitals in TB Care and Control
  • Guideline for Control of TB in Prisons
  • TB Infection Control Framework
  • Research e.g. introduce new diagnostics, new
    tools and transmission, shortened regimen for MDR
    TB, Phase IIb drug trials
  • Global TB Report
  • Development of regional institutions for TB
    training and human resource development
  • Enhanced availability of quality drugs

24
Both detection and treatment in USAID Focus
countries have increased significantly
  • Source WHO

25
Contents and executive summary
  • Background
  • Epidemiology fighting disease in three groups
    general population, HIV-affected, MDR-TB
  • Fight against TB is well coordinated globally
    across a number of different actors, among which
    USG plays a leading role
  • USAIDs strategic approach
  • USG context means important legal and policy
    requirements and a Whole of Govt approach
  • By area, gt 90 of USAID resources spent on
    country-level activity
  • By activity, 75 of funding supports service
    delivery, 11 ME/HSS, 9 research
  • Solid gains made in many areas, e.g., HIV
    patients tested for TB, but large numbers of
    people still unreached
  • Challenges/areas of improvement and how we are
    working to resolve them
  • Developing scenarios helps us work through
    funding uncertainties and constraints
  • Working closely with Global Fund to address its
    constraints
  • Scaling up priority areas of MDR-TB treatment,
    HIV/TB diagnosis and treatment, private sector
    engagement and new technologies
  • Wrap-up considerations

26
Key challenges the USAID TB program must address
Issue
Topic
  • Financial
  • Programmatic
  • Uncertainty around funding
  • Gaps in Global Fund support
  • Capacity and cost constraints of managing MDR-TB
  • Slow uptake of proven interventions for TB/HIV
    and other new service delivery and diagnostic
    approaches
  • Insufficient scale-up of new strategies
  • Inadequate lab capacity
  • Lack of optimum efficiency in scale-up of new
    technologies

27
Financial challenge uncertainty around funding
1
Description
Response
Rationale
Budget scenario
  • Funding levels described in GHI (2.2 bn over 6
    years)
  • Maintain number of countries per original
    projections
  • Continue research
  • N/A
  • Funding remains at 2010 levels, with slow growth
    thereafter
  • Reduce priority countries up to 5 by
  • Accelerating graduation
  • Discontinuing programs not yet taken to scale
  • Delay entry into vaccine research
  • Focuses resources on core activities and
    countries
  • Preserves integrity of continuing programs
  • Funding returns to 2008 levels, with slow growth
    thereafter
  • Reduce priority countries up to 9
  • Reduce role in late-stage research
  • Propose reduction to Global Drug Facility
    (legislated)
  • Reduce involvement in Stop TB Partnership
  • Programs protected as per base case
  • Unlikely to achieve GHI treatment targets
  • Lower case detection rates
  • Less treatment success
  • Impact on MDR

28
Financial challenge gaps in Global Fund support
Issue
Planned response
  • GFATM is a significant funding mechanism for TB
    program activity
  • Funding approved (through Round 9) in USG
    Priority Countries (historical)
  • Focus Countries 2.1 bn
  • Other Countries 5.2 bn
  • GFATM needs help in addressing funding challenges
  • Delays in grant signing
  • Suspension of funds, requiring USAID response to
    maintain core activities
  • Lack of reprogramming
  • Lack of transparency
  • Drug stock-outs
  • Set up GFATM for success
  • Use our access and voice within GFATM to improve
    performance
  • USG delegation on the GF Board
  • Technical Review Panel for the GF
  • GF CCM or sub committees at the country level
  • Use policy dialogue to shape provision of TA to
    countries to accelerate grant signing (currently
    against GF policy)
  • Target support and TA to develop grants, improve
    grant performance and remove grant bottlenecks
  • Strengthen TB TEAM housed in WHO to proactively
    prevent bottlenecks (rather than response)

29
Programmatic challenges capacity and cost
constraints of managing MDR-TB
  • Issue
  • Diagnosis of MDR TB will outpace capacity to
    treat, e.g., drug manufacturing capacity
  • Capacity to manage/ensure the quality of rapid
    scale-up of MDR-TB treatment not yet clear
  • Response
  • Transition from project to program-based MDR-TB
    management
  • Employ system-based approach consistent with
    USAID overall strength and experience
  • Extend treatment beyond facility to community
  • Help expand drug manufacturing capacity

treated of estimated cases of MDR-TB among all
notified cases of TB
Especially low in two regions with largest number
of cases
30
Programmatic challenge quick uptake of proven
interventions for TB/HIV but with room to grow
Proportion of TB patients tested for HIV in 40
USAID countries vs. world
Number of TB patients receiving testing and care
for HIV in 20 USAID focus countries
of TB patients
Real progress in TB patients tested for HIV but
absolute numbers still low
Testing for HIV improving but many TB/HIV
patients dont get ARVs
31
Our approach to expediting scale-up of TB/HIV
collaborative activities
Planned response
Issues
  • For PEPFAR Focus countries
  • Review successful and unsuccessful models of
    TB/HIV collaborative activities for lessons
    learned
  • Apply these lessons in national scale up modeled
    on successful programs
  • Increase country accountability for meeting
    TB/HIV targets
  • For non-focus PEPFAR countries, increase
    resources for TB/HIV needed to enable scale-up
  • Few HIV/TB patients with access to ARVs
  • TB/HIV collaborative activities not standard of
    care in all priority countries
  • Limited uptake of TB issues by HIV community
  • Result is slow uptake of three Is
  • Infection control
  • Isoniazid preventive therapy
  • Intensified case finding

32
Programmatic challenge insufficient scale-up of
new strategies
Description/ goal
Evidence for approach
USAID engagement
Mobilize communities
  • Mobilize CHWs to increase detection and treatment
    rates while decreasing costs
  • Tanzania reduced cost by 35 (27 for health
    services, 72 for patients)
  • Uganda treatment success rates from 56 to 74,
    costs halved
  • Ethiopia health extension workers manage a case
    for 39 of what it costs by general health workers
  • DRC community-based DOTS
  • Philippines 1840 treatment partners involved
  • Nigeria community volunteers referred almost
    5000 people for TB diagnosis
  • Ethiopia 1105 community extension workers
    engaged
  • Mozambique community volunteers referred almost
    19,000 people for TB diagnosis
  • Philippines private sector contributed 28 of
    new smear-positive cases detected in 2009
  • Engage the private sector to improve quality TB
    control and increase case detection rates
  • Philippines design and roll-out of innovative
    model to link private providers to national
    systems and insure national insurance
    reimbursement

Engage the private sector
33
Programmatic challenge inadequate lab capacity
Planned response
  • National strategic planning for labs and networks
  • Enhance support to Global Laboratory Initiative
    for country planning and monitoring (USAID and
    PEPFAR)
  • Accreditation and QA systems
  • Build evidence base / policies for most efficient
    use of new technologies
  • Support roll-out of new technologies

34
Programmatic challenges lack of optimum
efficiency in use of new technologies
35
Programmatic challenges lack of optimum
efficiency in use of new technologies example
of Xpert
  • Transformative new diagnostic technology which
    allows rapid diagnosis at district and
    sub-district levels
  • Programmatic challenges
  • Cost
  • Appropriateness (need stable electricity source)
  • Security issues (comes with a laptop)
  • Requires revised diagnostic algorithms

US millions
US millions
All TB HIVTB MDR-TB
All TB HIVTB MDR-TB
36
Wrap-up considerations
  • USG role is critical and growing
  • Countries in drivers seat, taking more ownership
  • Donors more coordinated but with lighter
    architecture
  • Key questions for discussion
  • Given funding constraints and our discussion of
    relative priorities, what aspects of the
    portfolio should be scaled back in the Base and
    Pessimistic funding scenarios?
  • Is there more that the USG/USAID can do to ensure
    the success of Global Fund grants?
  • What should be our role in scaling up new
    diagnostic tools such as Xpert, new drugs and new
    treatment regimens such as short course treatment
    for MDR-TB?
  • Next steps
  • Adjust programs to reflect FY 2011 and out-year
    funding situation
  • Follow up on todays discussion and
    recommendations
  • Work with you and other key partners on these
    challenges through the Federal TB Task Force
  • THANK YOU!
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