1. UPHOLD Strategy for Tuberculosis Control 2006/2007 Status Report May 2007 Presentation to Ministry of Health Officials

2. Overview of the Presentation Introduction/background Strategy for TB control TB control Activities Results/Achievements Challenges Lessons learned Way forward

3. 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

4. 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

5. Introduction and background (3) UPHOLD implements activities with a focus on ‘ 4 Rs ’: Results at people level Responsible speed in implementation Regional leadership and accountability Reaching out to and working principally with Ugandan institutions and systems

6. 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)

7. TB High Burden countries 2004/2005

8. 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)

9. 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

10. Community-based TB Care Referral System in rural settings

11. Baseline Targets LevelCase Detection rate(%) Treatment success rate(%) WHO/National Targets 7085 National target achieved 49 (2006)73 (2005) Targets for UPHOLD supported districts 42 (2006)78(2005)

12. 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

13. 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.

14. 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

15. CategoryDistricts 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 onlyBugiri, Mayuge, Kamuli, Kaliro, Mbarara, Kiruhura, Isingiro, Ibanda, Wakiso, Luwero, Nakaseke, Rakai, Lyantonde, Nakapiripirit, Bundibugyo, Kyenjojo

16. 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

17. Activities Build capacity for CB DOTS services in sub counties TB/HIV case management at health facilities TB 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

18. Activity implementation was rolled out in October 2006 at district level

19. 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

20. Outputs  Trained 382 Health workers in TB drug logistics 342 in CB DOTS/HIV  Supervisions 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%)

21. 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%

22. Results -Case Detection rate 2006 CDR2007 CDR 1 st Qtr Below target, CDR< 70% Above Target > 70%

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

24. 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

25. 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)

27. Results-Treatment success rate 20052006 1 st Quarter Above target, TSR≥ 85% Below target, TSR< 85%

28. Challenges Poor implementation of the TB/HIV Collaboration oCPT numbers not known at the beginning of treatment oTB 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

29. 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

30. 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

31. Thank you