1. GLOBAL FUND-SUPPORTED PARTNERSHIPS DO THEY WORK IN FAILED STATES? WV SOMALIA TB PROGRAM EXPERIENCE By Dr Vianney Rusagara, MD - World Vision Somalia and Dr Milton Amayun, MD - World Vision International

2. Somalia - Country profile Located in the horn of Africa Country with the longest seacoast in Africa - 3,000 km (Red Sea and Indian Ocean) Total area - 638,000 sq.km Population - 7.96 million Mostly semi-arid and desert Harsh environment, favours nomadic lifestyle One tribe, one language One religion (100% Muslim)

3. Somalia

5. Political situation No unified government for the last 15 years 3 distinct geopolitical and autonomous zones (Northwest, Northeast, South/Central) Northwest (Somaliland) declared as a break away republic in 1991 Northeast (Puntland) 1998 Traditional governance used in some areas Warlords control some areas of South/Central Somalia

6. Geopolitical subdivisions North West (Somaliland) North East (Puntland) South/Central

7. Somalia ….. ….is mainly arid some areas have water – especially the south

8. Effects of long conflict The prolonged civil war destroyed health and social service infrastructure Most parts have been under a complex humanitarian emergency Health sector probably the most affected Infectious diseases are prevalent TB - among top 3 public health problems Services mainly by INGOs and UN agencies

9. Effects of conflict….. Vulnerable displaced population

10. Effects of conflict…. Many major towns were left in ruins Some towns needed to be restored

11. Current health indicators Infant Mortality Rate130/1000 live births Under 5 mortality Rate219 /1000 live births Maternal mortality Ratio1,600/100k (2004) Life expectancy at birthM/F: 43/45 (years) BCG coverage - 1 year old 35% (2006) Measles coverage - 1 year old 22% (2006) TB Incidence372/100,000 HDI0.299 (2005) Purchasing Power Parity$600 (Rank: 193)

12. Somalia TB Program Reactivated in 1995 by WHO and NGOs Funding entirely external By 2002, there was a good foundation Further expansion required more funds 2003: a 5-year proposal for TB control was approved by the Global Fund

13. Global Fund TB Program Multi-partnership – 10 INGOs, WHO and local organizations, governments – MOH, a private firm, multilateral agencies Somalia Aid Coordinating Body = CCM Most activities based in Nairobi WVI - Somalia selected Principal Recipient to replace WHO.

14. Program Goal and Objectives Goal To decrease TB morbidity and mortality Main Objectives 1. Increase access to TB services 2. Improve quality of the program with treatment success rate > 85%

15. TB Patients… Some patients present at late stages with complications

16. Main Activities Support essential Human Resource Improve infrastructure and provision of essential equipment Training/Planning Procurement and distribution of drugs and lab supplies

17. Main Activities…. Training Health workers at end of training session

18. Main Activities.... To strengthen TB Information System Produce/Distribute Information Education and Communication (IEC) materials

19. Main Activities…. Monitoring and Evaluation:  Close supervision and monitoring  Microscopy quality control  Quarterly and Mid-Year Program Reviews  Operational research, external annual audit / evaluation Supervision and monitoring team with some staff at a TB facility

20. Awareness raising and Health Education Health education is conducted before dispensing anti TB drugs to patients Mobilization and awareness on TB (and HIV/AIDS) in a community

21. Program Budget Phase 1: 2years (Oct 2004 – Sep 2006) - US$ 8,224,136 Phase 2: 3 years (Oct 2006 – Sep 2009) - US$ 8,224,136

22. Implementation arrangements Roles of partners clearly defined WHO – technical advice, training, research WV - overall program management Supervision/M&E - WV assisted by an INGO with national program coordinators Coordination team chaired by WV Program data recorded and reported using standard WHO information system on TB

23. Program partners’ architecture CCM - Country Coordinating Mechanism HSC - Health Sector Committee TBCT - TB Coordination Team TB WG - TB Working Group ECHO -EC Humanitarian Office

24. TB Treatment facilities before Global Fund support (at end 2004)

25. TB Treatment facilities opened with GF Fund support (at end 2006)

26. Program Results - Case notification Case detection increased 49% (2004) to 60% (2006)

27. Somalia TB Program - Case notification Trend

30. Program Results Treatment Outcome Treatment success rate ca. 90%

31. Somalia TB Program Treatment Outcome 1995 - 2005

34. Other Results……. Results in almost all the indicators - above targets Tuberculin survey – Incidence decreasing Phase 1 GFATM evaluation awarded an “A”

35. Impact of the Global Fund Program Global Fund has enabled continuity of TB service in Somalia There are remarkable achievements in a short time Program staff supported

36. Impact of the Global Fund Program Coordination for a has brought together the Ministries of the 3 (sometimes) warring authorities Cured patients have become advocates and stigma has drastically reduced Given Hope to very poor communities. Set an example to many other programs in Somalia.

37. Coordination Mid term review: Donor (GFATM), Private, Multilateral, Government Authorities, Civil society partners represented

38. Challenges Geopolitical divisions Insecurity, limited access to some areas Mobile populations Limited resources – some gaps Weak health delivery system TB / HIV Multi Drug Resistance

39. On faith issues… WVI is well known as a Christian INGO. The combination of professionalism and longevity in Somalia was its platform to work on a nationwide TB program. Respect for Islam, sensitivity to local practices and definitely no proselytism. Key: Transparency, openness and frequent consultations are the key Plus: Caring staff in a harsh environment.

40. Lessons learned… What did not work well Due to multi-partner nature: Initial misunderstanding on roles and responsibilities – detailed TORs needed! Local authorities: control issues. Supervision/Monitoring teams denied access in some areas. “These were resolved through constant dialogue and coordination”

41. Lessons learned …. What worked well Partners should be well chosen for complementary strengths. Country program decisions on TB taken jointly in a pre-agreed upon process. Corrective accountability: solve problems immediately – before they become crises. Performance-based concept works in fragile/failed states as in stable countries.

42. Conclusion….. “When resources are available, well designed and implemented programs by professional and caring staff can succeed anywhere - even in FAILED states.”