1. Global Fund Grant Proposal Round 11: Tuberculosis Nathan Furukawa Gabriella Boyle Rebekah Miner Paa Kobina Forson Xiaoxue Huang Hunter Pugh Gap Analysis

2. Tuberculosis Burden 22 High Burden TB countries account for 80% of the world's TB cases- Cambodia is one of those high burden countries as identified by the WHO. Cambodia leads the region in incidence, prevalence, and deaths due to TB 1993 Reestablishment of the national DOTS program History of GF grants Round 2, 2004: Tuberculosis Grant: Decentralization Round 5, 2006: Tuberculosis Grant: Scaling up Rural TB & TB/HIV Services Round 7, 2009: Tuberculosis Grant: MDRTB, TB/HIV, and Lab Services

3. Tuberculosis Incidence Incidence: 62,000 new cases 437 per 100,000 population

4. Tuberculosis Deaths TB Deaths: 8,600 deaths 61 per 100,000 population

5. Tuberculosis Case Detection Case Detection: 65%

6. Provincial Map 100% DOTS Coverage Rate DOTS availability (2007): 41 health operational districts (of 77 total) 461 Health Centers (of 966 total) 80% of the population is rural 21% of poorest 1/5 of the population travel 5km+ to reach a health center.

7. Treatment, MDR-TB, and HIV Strength: Treatment SuccessUnknown Threat: MDR-TB Reach of HIV services does not extend as far as the decentralized DOTS program The main barrier relates to limited access to culture for diagnosing sputum smear-negative disease 70-100% of all newly diagnosed HIV-infected persons screened for TB, but only 14-83% of TB patients were tested for HIV. The rate of active disease found upon screening ranged from 9% to 26%. The HIV/TB Disconnect

8. Inputs and Activities Promoting Decentralization -Expansion of basic services rurally by expanding DOTS to all health centers -Operational research funding Improving Case detection -Implement active case finding -Private sector engagement -Mobile microscopy service pilot Diagnostics -Expand access to diagnostics rurally -Establish Universal DST access means Healthcare Worker Training -2.3 doctors and 7.9 nurses per 10,000 -Training low skilled health workers DOTS Structural Support -Funding security -Streamlining coordination within decentralized system Drugs Procurement -59,784 people require treatment -Secure 1 st line drug supply chains -Stockpile 2 nd line drugs HIV/TB Service Expansion -Coordination of TB and HIV scale up by health center catchment Vulnerable Populations -Targeting of impoverished, slum areas, and ethnic minorities

9. Some Outputs Promoting Decentralization -Improved access to DOTS rurally Improving Case detection -Achieve case detection above 75% -Increase % completing treatment Diagnostics -Characterize MDR-TB burden -Streamline diagnosis and treatment Healthcare Worker Training -Task shifting without internal brain drain DOTS Structural Support -Coordinated data collection -Sustainability Drugs Procurement -Avoid stockouts -Access to MDR/XDR-TB Treatment HIV/TB Service Expansion -Integration of services -Improved health metric outcomes Vulnerable Populations -Reducing TB clusters and health disparities

10. End

11. Random Slides

12. Case Finding Gaps

13. Tuberculosis Treatment, Care and Support # of treatment units implementing DOTS Treatment, Care and Support # of estimated new smear- positive TB cases detected under DOTS Treatment, Care and Support # of smear-positive TB cases registered under DOTS successfully treated* Treatment, Care and Support # of persons completing DOTS+ treatment for MDR-TB*

16. Resources dedicated to or consumed by the program What the program does with the inputs to fulfill its mission Direct products of program activities Goal attainment IMPACT Political commitment Allocates the highest percentage of government’s budget on health (16%). Still insufficient: 2002 was $2.7 per capita and about $5.8 in 2009. Below minimal care package of $12 per person

17. Brief History 1863 - Cambodia becomes a protectorate of France. French colonial rule lasts for 90 years. 1953 - Cambodia wins its independence from France. 1975 - Khmer Rouge led by Pol Pot occupy Phnom Penh. Year Zero starts. The total death toll during the next three years is estimated to be at least 1.7 million. 1979 The Vietnamese take Phnom Penh. Pol Pot and Khmer Rouge forces flee to the border region with Thailand. 1993 The MoH reestablishes its long nascent national TB program