Compiled by Global Fund Coordinating Unit (GFCU) Ministry of Finance (MOF) June 2013
(i) Host Country : Lesotho (ii) Grant Number : LSO-607-G04-T (iii) Program Title (iv) Areas of Focus : Reducing Morbidity and Mortality due to TB by Community Involvement in TB Control : Tuberculosis (v) Implementation Period : 1st July 2007-30th June 2012 (vi) Global Fund Grant Amount : $5,543,667.31. (vii) Principal Recipient Name : Ministry of Finance i
Table of Contents ACRONYMS ------------------------------------------------------------------------------------------iii EXECUTIVE SUMMARY -------------------------------------------------------------------------------iv Chapter 1: Introduction and Background Information --------------------------------------------------------------------------------1 1.1 Introduction -------------------------------------------------------------------------------------------------------------------1 1.2 Background information -----------------------------------------------------------------------------------------------------1 1.3 Goal, objectives and major activities of the grant ----------------------------------------------------------------------1 1.4 Implementation arrangements ----------------------------------------------------------------------------------------------1 1.5 Financing arrangements ------------------------------------------------------------------------------------------------------2 1.6 Procurement ------------------------------------------------------------------------------------------------------------------2 Chapter 2: Program and Financial Accomplishments --------------------------------------------2 2.1 Program Achievements -------------------------------------------------------------------------------------------------------2 2.1.1 Improving diagnosis ---------------------------------------------------------------------------------------------------------2 2.1. 2 Provision of High Quality DOts ----------------------------------------------------------------------------------------------3 Treatment Success Rate (TSR) ----------------------------------------------------------------------------------------------3 2.1. 3 Community TB care ----------------------------------------------------------------------------------------------------------3 2.1.4 Advocacy Communication and Social Mobilization (ACSM) -------------------------------------------------------------4 2.1.5 TB/HIV -------------------------------------------------------------------------------------------------------------------------5 2.2 Discussion of programmatic achievements --------------------------------------------------------------------------------6 2.2.1 Improving diagnosi-------------------------------------------------------------------------------------------------------------7 2.2.2 Provision of High Quality DOTS ---------------------------------------------------------------------------------------------8 2.2.3 Community TB Care ---------------------------------------------------------------------------------------------------------9 2.2.4 Advocacy Communication and Social Mobilization (ACSM) ------------------------------------------------------------10 2.2.5 TB/HIV -------------------------------------------------------------------------------------------------------------------------11 2.3 Financial Accomplishments -----------------------------------------------------------------------------------------------12 2.3.1 Budget and expenditure by categories -----------------------------------------------------------------------------------12 2.4 Overall Programmatic Achievements and Impacts ---------------------------------------------------------------------13 Chapter 3: Sustainability plan & Lessons learned ------------------------------------------------14 3.1 Sustainability Plan ----------------------------------------------------------------------------------------------------------14 3.2 Lessons Learned ------------------------------------------------------------------------------------------------------------ 15 3.2.1 Grant implementation arrangements ------------------------------------------------------------------------------------15 3.2.2 Partnerships with donors, civil society, private sector, etc.---------------------------------------------------------- 15 3.2.3 CCM functioning and oversight challenges -------------------------------------------------- ------------------------16 3.2.4 Global Fund grant management process including working relationships with Global Fund Secretariat and LFA.--------------------------------------------------------------------------------------------------------- 16 Chapter 4: Conclusion and Recommendations -------------------------------------------------17 4.1 Conclusion --------------------------------------------------------------------------------------------------------------------17 4.2 Recommendations ---------------------------------------------------------------------------------------------------------- 17 4.3 Annex one: Programme achievements in pictures-----------------------------------------------------------------------18 ii
ACRONYMS ACSM ART CDR CHAL CHW CPT DHS DHMT DOTs HCW ICAP IPD LFA M&E MOH NDSO NTP OPD OSDV PIH : Advocacy Communication and Social Mobilization : Antiretroviral Treatment : Case Detection Rate : Christian Health Association of Lesotho : Community Health Workers : Cotrimoxazole Preventive Therapy : Demographic and Health Survey : District Health Management Team : Directly Observed Treatment- Short Course : Health Care Workers : International Center for AIDS Care and Treatment Programs : In- patient Department : Local Fund Agent : Monitoring and Evaluation : Ministry Of Health : National Drug Service Organization : National TB Programme : Out-patient Department : Onsite Data Verification : Partners In Health PMTCT : Prevention of Mother To Child Transmission PR SDA SR TSR TB : Principal Recipient : Service Delivery Area : Sub- Recipient : Treatment Success Rate : Tuberculosis UNICEF : United Nations Children Fund WHO : World Health Organization iii
EXECUTIVE SUMMARY At the end of June 2012, the Round 6 TB grant came to close after being implemented for five years. As part of the grant closure procedures, the country is required to prepare a final report to illustrate the successes and the challenges that occurred during implementation, and to estimate the overall contribution of the grant to the country s response in addressing the health challenges. This report presents the key achievements, challenges and lessons learned in the implementation of the Round 6 TB grant in Lesotho. The goal of the grant was to reduce the morbidity and mortality due to TB in Lesotho. This goal was compatible with that of the National TB Strategic DOTS expansion Plan 2008-2012 and also line with the Millennium Development Goals and Stop TB Strategy. Specifically the grant focused on raising case detection of estimated smear positive cases of TB to 70% and achieving treatment success rate of 85%. Due to the contribution of this grant, NTP has maintained a high level of TB case detection rate which has surpassed the WHO global target of 70%. CDR was 90% in 2009, 85% in 2010 and 82% in 2011. A high and sustained CDR is important in that incidence will eventually fall. Timely identification and complete treatment of tuberculosis patients requires the support and participation of their community members. Community involvement enhanced TB case detection rate through increase awareness of the disease leading to stigma reduction, and provision of treatment support to patients thereby increasing convenience. This represents a significant achievement in the national efforts to fight TB. The treatment success rate has always fallen short of the WHO Global target. The low performance can be attributed to several factors. On average mortality has been at around 10% and this considered high, the proportion of cases not evaluated has been very high at around 10%. Defaulter rate as observed has also been on the increase, 8% was recorded in 2010 compared to 5% in 2007. That implies that improved treatment outcomes can be realized if mortality, defaulter rate and unevaluated cases are significantly reduced. The country did not reach the minimum standard during the implementation of the grant and these calls for a review of the current strategies employed by the country. At the programmatic level, one of the major achievements under the round 6 grant is that, it introduced community interventions that were aimed at empowering communities to take active part in TB care, treatment and support of TB patients. The involvement of community structures as well the ACSM in the TB care were new approaches which the NTP was implementing. There was also tremendous capacity created on monitoring and evaluation system for the National TB program which was initiated under round 2 TB grant. These efforts were further strengthened under the round 6 grant and these included the review of existing data collection tools to incorporate reporting on community based interventions. Furthermore there was also the review of existing tools such as the TB register to include data on TB/HIV collaborative activities. Absorptive capacity of finance earmarked for this grant was achieved at 73%. It is imperative to improve the absorption of funds to ensure that Lesotho can continue to receive substantial financial support for interventions that would ensure the country is able to achieve and surpass WHO target of Treatment success rate, therefore reduced TB Patient mortality in future. Highly skilled and motivated workforce is required and needed by the Country. As a way forward, the country with the assistance of development partners should direct resources to high impact interventions in order to improve the treatment outcomes. Furthermore there is need to support and ensure that annually Health resource mapping is conducted so as to reduce duplication of efforts by various MOH partners. As such coordination and transparent information is required from the Donor community to avoid duplication of efforts, which in most instances lead to low absorptive of funds. Such an effort could help to free resources to other interventions that are under funded. Finally the issue of sustainability of the interventions initiated under external support will always pose a challenge to government since the government budget cannot always meet the donor resources when the donor phases out. As such future proposals should attempt to include the issue of sustainability during the proposal development phase to avoid challenges. In conclusion it can be deduced that the grant made significant contribution by increasing financial resources to support interventions articulated in the National TB Strategic TB/HIV Plan 2008-2012 and National TB Strategic DOTS expansion Plan 2008-2012. iv
Chapter 1: Introduction and Background Information 1.1 Introduction This report takes stock of the contribution made by the Round 6 TB grant in the national efforts to fight tuberculosis in Lesotho. The report is organized into four chapters. The first chapter gives an overall background for the entire Global Fund support in Lesotho as well as the objectives and activities supported under the grant. Program achievements are discussed in chapter two. Chapter three looks at the sustainability plan and lessons learned from the grant implementation. Chapter four looks at the conclusion and the recommendations. 1.2 Background information The Global Fund to fight AIDS, TB and Malaria (GFATM) has been supporting the Government of Lesotho with financial resources to fight HIV/AIDS and TB since 2004. The Ministry of Finance is the Principal Recipient (PR) responsible for coordinating and managing these grants, while Ministry of Health has been the major Sub Recipient for all these grants of TB or HIV/AIDS. For the round 6 TB grant, the Sub Recipients was the Ministry of Health and implementation of activities was undertaken by the National TB Programme. 1.3 Goal, objectives and major activities of the grant The goal of the grant was to reduce the morbidity and mortality due to TB in Lesotho. This goal was compatible with that of the National TB Strategic DOTS expansion Plan 2008-2012 and also line with the Millennium Development Goals and Stop TB Strategy. Specifically the grant focused on raising case detection of estimated smear positive cases of TB to 70% and achieving treatment success rate of 85%. Two objectives were identified to guide implementation of activities under the grant through the different service delivery areas. The first objective focused on empowering people with TB and communities to provide treatment, care and support to TB patients while the second objective dwelt on addressing TB/HIV through TB/HIV collaborative activities. These objectives were congruent with the two strategic objectives of the National TB Strategic DOTS expansion Plan 2008-2012. Accomplishment of the first objective consists of the implementation of the following main activities; Conduct baseline Studies on Community Participation on TB Care Strengthening of National TB Program Central Office and Health Education Division capacity to spearhead TB Advocacy, Communication, and Social Mobilization (ACSM) activities Improving and strengthening lab infrastructure and health education infrastructure by procuring equipment Conducting countrywide sensitization activities in communities on TB issues Training of Health Care Workers on how to involve communities in TB Care Improve TB knowledge of community leaders (chosen from local governing authorities) through TB Education seminars Improving delivery of TB services to vulnerable populations by mapping populations and improving monitoring and evaluation Improving referral system of TB suspects by communities to TB services Establishing or upgrading infrastructure of laboratory services Providing laboratory equipment and supplies necessary for TB diagnostics for all HSA laboratories Strengthening capacity building for laboratory personnel Support TB operational research Main activities identified towards the attainment of the second objective focused on: Providing HIV testing and counseling Services to all TB patients with all health centres Introducing HIV prevention methods in TB clinics Introducing cotrimoxazole prophylaxis Training of Health Workers in TB Clinics to provide HIV/ AIDS care and support Training health workers on referral TB/HIV mechanisms 1.4 Implementation arrangements The Principal Recipient under this grant was the Ministry of Finance while the Sub recipient was the Ministry of Health. The implementation was undertaken by NTP with the ad- 1
ditional support from PIH as the SSR. 1.5 Financing arrangements The Global Fund operates on the principle of the performance based funding model. Budgets and expenditure are linked to activities of the grant. Disbursement of funds to the PR is based on the absorption capacity of the PR through the SRs. During the implementation of this grant funds were disbursed to the SR by the PR. This was done because the SR was assessed and was found to have the required capacity to manage the funds and report accordingly through the Ministry s Project Accounting Unit (PAU) which is responsible for managing donor funds for the Ministry. In addition the periodic trainings on the management of the Global Fund grants were held during the implementation of the Round 2 grant and both PR and SR gained valuable experience from those trainings. 1.6 Procurement The procurement unit from the Ministry of Health and NDSO were also assessed and found capable to support the procurement of goods and services for both non-health products, health products and medicines products respectively. As a result the PR engaged both the Ministry of Health and NDSO to support procurement activities under the grant. Chapter 2: Program and Financial Accomplishments 2.1 Program Achievements The goal of the grant was to reduce the morbidity and mortality due to TB in Lesotho. This goal was compatible with that of the National TB Strategic DOTS expansion Plan 2008-2012 and also line with the Millennium Development Goals and Stop TB Strategy. The grant consisted of two objectives and these, included empowering people with TB and communities to provide treatment, care and addressing TB/HIV through TB/HIV collaborative activities. The grant achievements under this grant will be based on the Service Delivery Areas. These include improving diagnosis, provision of high quality DOTs Strengthening Community TB, Advocacy Communication and Social Mobilization and TB/HIV. 2.1.1 Improving diagnosis Under this SDA, one indicator was used to assess the performance of the grant and this is Case Detection Rate. The indicator is internationally recognized for assessing the effectiveness of the NTP control programs and it is key to the WHO global Stop TB strategy. During the implementation of this grant the following results were achieved in Lesotho. Fig. 1 2
Cases Detection Rate (CDR) The CDR measures the rate at which new cases are identified and treated under the national DOTS strategy. The WHO minimum standard for the case detection is at least 70%. NTP has maintained a high level of TB case detection rate which has surpassed the WHO global target of 70%.CDR was 90% in 2009, 85% in 2010 and 82% in 2011. A high and sustained CDR is important in that incidence will eventually fall. Timely identification and complete treatment of tuberculosis patients requires the support and participation of the community members. Community involvement enhanced TB case detection rate through increase awareness of the disease leading to stigma reduction, and provision of treatment support to patients thereby increasing convenience. 2.1.2 Provision of High Quality DOts Treatment Success Rate (TSR) According to the NTP annual Report (2011), Lesotho as a country has not performed well on improving treatment outcomes. The target under the grant was to reach a treatment success rate of 85% in line with WHO target during the five period. The treatment success has always fallen short of the WHO Global target. The low performance can be attributed to several factors. On average mortality has been at around 10% and this considered high, the proportion of cases not evaluated has been very high at around 10%. Defaulter rate as observed has also been on the increase, 8% was recorded in 2010 compared to 5% in 2007. That implies that improved treatment outcomes can be realized if mortality, defaulter rate and unevaluated cases are significantly reduced. The country did not reach the minimum standard during the implementation of the grant. The Ministry and its technical partners such as ICAP are already working collaboratively to implement strategies that will improve performance of the country on this indicator. 2.1.3 Community TB care The main focus of this SDA was to create capacity of the community health workers to carry out interventions promoting health seeking behavior in the community. In addition the capacity of the health care workers was to be built on how to involve communities in TB care. Community Health Workers are frontline health care providers to deliver various public health services at the community level. These services include promotion of good health practices in the community, provision of preventive and curative health care through education, referral of suspects to health facilities. Under this grant, provision was made for training CHW to strengthen referrals of TB suspects. By the end of the grant 2238 TB suspects were referred by the CHW. The performance was considered unsatisfactory. Two main factors contributed to the low performance firstly in phase 1 the NTP had no yet developed a proper tool for recording and reporting community referrals, secondly it assumed that due to high level of TB awareness (94%, DHS 2009), suspects seek health service without the involvement of the Community Health Workers. Furthermore during the implementation of this grant, over 2500 CHWs received training on community TB care. The training equipped the CHW on a variety of areas in health care. These training were intended to 3
empower CHW to promote health seeking behavior at the community and contribute in improving treatment outcomes. In addition over 850 health care workers have been trained on community TB and TB/HIV collaborative activities. These trainings equipped the HCW with skills to manage TB/HIV collaborative activities and community TB care. These interventions were geared towards improved access to TB diagnosis and quality patient-centered care through community participation and better capacity of the health work force. 2.1.4 Advocacy Communication and Social Mobilization (ACSM) Advocay, Community and Social Mobilization and community participation in TB care constitutes important strategy in intensifying case finding of TB and the overall care of TB 0f patients for improved treatment outcomes. The interventions under this SDA were aimed at increasing TB awareness at community level through rolling out of the ACSM activities at the community. 4
Under the Round 6 grant the central NTP Programme and Health Education Division were capacited to spearhead TB ACSM activities. Officers within NTP and Laboratory department were provided with financial support to attend shorterm courses and long term trainings in order to strengthen NTP Programme and Laboratory services in human resource capacibilites. One candidate obtained Master s degree in Health Education and while One laboratory staff member was enrolled into long term training at the University of the Free State where she obtained BSc in Medical Microbiology to improve capacity within the National Laboratory Service. In addition, 30 microscopists were supported as part of laboratory strengthening to improve efficiency of smear microscopy in the country. With regard to Health Education Division, thirteen(13) Health Educators were recruited under the grant. Three of them were placed at the central level while ten were stationed at the districts within the DHMTs. Their key mandate was to coordinate all the ACSM activities at the district level. During the grant implementation all the health educators developed the District annual ACSM plans which articulated ACSM activities to be undertaken in collaboration with other stakeholders in the ten districts. More importantly these interventions were intended to promote health seeking behaviour from the communities in order to improve treatment outcomes. Furthemore 1,957 community leaders received training on social mobilization and communication.the main aims of these trainings was to capacitate the leaders so that they can impart the knowledge acquired to their respective communities. Due to the contribution of this grant the community leaders are now considered as one of the key health partners in the health care system. Efforts to intensify TB at the community level were scaled up. 5000 IEC TB posters 800 pins with TB messages and 20 000 leaflets were printed and distributed. These IEC material focussed on educating the community about the signs and symptoms of TB, the importance of adherence treatment, TB/HIV collaborative activities and the overall care reqquired for HIV possitive TB patients, family support for TB patients. The TB posters were pasted in health centres and hospitals OPD and IPD to enable patients have access to the information. Some of the leaflets were given to the general public during the public gatherings. Radio spots were conducted in local radio stations to reach a wider population with TB and HIV messages. These radio spots were employed as one of the strategies used in creating awareness on TB, TB/HIV collaborative activities. In addition 15 journalists were trained on TB issues so that they can accuretly disseminate information on TB through print media in order to provide correct information to the general public. Furthermore, the training focused on providing key information about TB, the relationship of TB with HIV, and the importance of adherence. 2.1.5 TB/HIV The implementation of this grant coincided with the implementation of the National TB Strategic TB/HIV Plan 2008-2012 and the grant supported capacity building efforts in the rolling out of TB/HIV collaborative activities in the country. The grant made significant contribution in the scale up of the TB/HIV collaborative activities. This was through training of HCW on TB/ HIV collaborative activities. These HCW encompasses nurses and doctors in public and private facilities. The trainings focussed on the implementation national guidelines which includes, routine HIV counselling and testing among TB patients, PMTCT in Pregnant in TB patients, initiation of TB patients on ART. These interventions were aimed at reducing the burden of both TB and HIV/AIDS to people infected or affected as highlighted in the TB/HIV NSP 2008-2012. As result of this grant TB/HIV collaborative activities were scaled up in all the ten districts of the country. As shown by the table below. 5
HIV counseling and testing uptake within the TB patients has been increasing over the past five years. As shown above, the proportion of people who received HTC was 51% in 2007 and increased to 83% in 2011. According to the national guidelines all TB patients should receive HIV testing and counseling, however HIV testing and counseling is still voluntary meaning patients can opt out after attending counseling sessions. The current performance has become stagnant and declined at 76% when compared to 2007 at 80%. Enrolment of HIV positive TB patients on CPT is above 90% in 2011 and though below the national target of 100%. The highest performance was recorded in 2010, where 96% of HIV positive patients were on CPT. Based on the national guidelines all HIV positive TB patients should receive CPT to prevent other opportunistic infections. The proportion of HIV positive TB patients on ART is steadily increasing. As observed, in 2011 40% of HIV positive TB patient were put on ART. The coverage is still low however it is on the increase when compared with the previous early years of implementation. The grant made significant contribution in the scale up of the TB/HIV collaborative activities. 1308 HCW received training of TB/HIV collaborative activities during the five year period. These HCW encompassed nurses and doctors in public and private facilities. The trainings focused on the implementation of the national guidelines which includes, routine HIV counseling and testing among TB patients, PMTCT in Pregnant in TB patients, initiation of TB patients on ART. Through the round 6 grants the capacity of the health facilities in terms of knowledge and skills was improved through the training of health care workers in order to deliver appropriate care on co-infected patients. Hence the grant made a significant contribution in the provision of TB/HIV collaborative activities. 2.2 Discussion of programmatic achievements The Round 6 grant implementation period started in July 2007 to June 30 2012. A lot of activities were conducted and achieved huge accomplishments. However, 6
the most important thing to establish is whether the grant had a meaningful contribution in terms of improving the TB treatment outcomes in Lesotho in the past five years of its implementation period. The following section explores this question using the five assessment criteria. Efficiency: Efficiency is measure of the relationship between the inputs, in this case financial resources and outputs meaning the units of service or other tangible benefits experienced by the target population included within the scope of the grant. Did the activities under the round 6 provide adequate results given the resources available? Effectiveness: Effectiveness is the measure of whether or not a particular intervention achieved the goals or objectives it was meant to achieve. For example if the grant to reach 100 community leaders with IEC material, did achieve these results. Relevance: Relevance addresses the overall aim or goals of the programme of action. Was the overall goal of the grant appropriate given the environmental conditions that existed when the original proposal was developed? If there were significant changes in the operating environment during the implementation of the grant, were appropriate adjustments made to the programme of action and the implementation arrangements? Impact: Impact measures the extent to which a programme of action makes meaningful difference on the situation that gave rise to the development of the programme in the first instance. In the case of the round 6 grant, it was meant to contribute to empowering communities in TB care, treatment and support of TB patients. Sustainability: One of the intents behind the creation of the Global Fund was to build effective health systems and structures in recipients countries to enable them to manage health and development challenges associated with HIV and TB in the case of Lesotho. Once built, it was intended that countries would sustain these systems on their own. It was intended that capacity gained as a result of the Global Fund investment would remain long after grant implementation was complete. What was intended as sustainable interventions for Lesotho under the round 6 grant and what remains now that the grant is closed? The discussion of the performance round 6 grant in relation to these five criteria follows. 2.2.1 Improving diagnosis Since phase 2 of the grant significant number of PTB cases were detected smear microscopy, in 2009 the proportion of PTB cases detected through smear microscopy was 80%, while in 2010, it was 79% and in 2011 it increased to 93%. This serves as clear indication that the Round6 grant contributed in scaling the efforts towards the improving TB in diagnosis in Lesotho. Table 4: Improving diagnosis Efficiency ++ Microscopy services can be done in different setting including at health centres to ensure the provision of services. This was achieved through provision of Reagents and commodities, Laboratory equipment such as deep freezers and safety cabinets and microscopy services through availablility of 30 Microscopists to improve the quality of laboratory services in all district hospitals. Further more, training of the microscopists was supported and Refurbishment of Hospital Laboratories in Quthing and Mohale s hoek hospitals as well as those in CHAL Facilities in St. James, Mantsonyane and Tebellong. Effectiveness ++ Improved case detection rate as result of strengthened microscopists services. Relevance Yes The CDR continued to surpass the WHO recommended minimum requirements during the grant implementation. Impact ++ Improve diagnosis has led to improved case detection and treatment strategies. Sustainability + Microscopy services are currently integral part services of health services package. Legend No: - Not Clear: ±, Adequate; + Exceptional: ++ 7
Caption: Through R6 TB grant microscopists were deployed and lab equipment procured to improve TB diagnosis. On the left is the microscopist in Mafeteng hospital lab conduct microscopic tests while on the right is microscopists in Mohale s hoek hospital conduct sputum test using safety cabinet. The grant had a tremendous impact in creating the capacity for improving diagnosis services for timely detection of the TB in the health facilities. This has led to patients being put on treatment on time. 2.2.2 Provision of High Quality DOTS Over the implementation of the round 6 grant TSR has remained below the recommended WHO global targets. The issue of concern was whether the current strategies implemented by the NTP were not effective. One of the key observations on the treatment outcomes data was that on average mortality within TB patients was at around 10% while the proportion of unevaluated case on average 11%. These two indicator calls for evaluation of the current strategies since as long as they remain at these levels TSR will not improve to the expected levels. Table 5: Provision of High Quality DOTS Efficiency ++ Different cadres of health care workers and the community leaders were trained on DOTs under the grant and that formed a basis for the empowering the communities in TB care. Effectiveness ++ Capacity building of the community structures such as the community leaders, Community Health Workers ensured the full participation of the community TB for improved treatment outcomes. Relevance Yes DOTs remain a proven strategy for successful treatment of TB, though TSR remained low during the grant implementation of the grant. Impact + Communities are active members in TB care and this will lead improve treatment outcomes Sustainability + Dots remain one of the key strategies in the NTP strategic Plan and as such the Ministry of Health and its technical partners will continue to avail resources for implementation. Legend No: - Not Clear: ±, Adequate; + Exceptional: ++ 8
Caption: On the left are Community leaders and on the right are health workers receiving training workshop to improve TB care during phase 2 of the grant implementation. While it has been recognized that the grant made significant contribution in the expansion of DOTs in Lesotho, TSR remains below the minimum requirements from WHO and other Global Targets. It is incumbent that, when moving forward the current strategies are reviewed to reverse the current trends in TSR. 2.2.3 Community TB Care One of the key objectives of this grant was to empower people with TB and communities to provide treatment, care and support to TB patients. To achieve this objective the key strategies included training of the health workers on how to involve the communities in TB care, Training of Community Health Care on strategies to improve health seeking behavior in the community and improve referrals. Table 6: Community TB care Efficiency ++ Health Care Workers were capacitated on how to involve community in TB. Community Health Workers were trained on promoting health seeking behavior form the community and these included strengthening referrals. Effectiveness ++ A significant number of both health care workers and community health workers were reached with trainings. Relevance Yes To improve the CDR and the TSR it was critical that both the health care workers and Community Health Care Workers are well capacitated. Impact + The good performance in CDR can be attributed to these interventions. Although a much work is still needs to be done to improve TSR Sustainability + Community participation in TB care and treatment remains one of the key strategies in the NTP strategic Plan and as such the Ministry of Health and its technical partners will continue avail resources for this intervention. Legend No: - Not Clear: ±, Adequate; + Exceptional: ++ Caption: Community Health Workers receiving training on community TB care and support. 9
It is evident that the grant made huge contribution in scaling out activities that were geared towards community participation in TB care and treatment. And as such it is crucial that the Ministry push for more efforts that will involve the communities to participate in TB. This will go a long way in improving the treatment outcomes. 2.2.4 Advocacy Communication and Social Mobilization (ACSM) Advocacy, Community and Social Mobilization and community participation in TB care constitute an important strategy in intensifying case finding in TB. Under this grant efforts were made to scale up the ACSM interventions. Central to these interventions was capacity building on the community leaders on TB, strengthening the District Health Education at the districts to roll out the ACSM activities to the community level. Table 7: ACSM Efficiency ++ District Health Educators were recruited under the grant and deployed in all the ten districts. Equipment was purchased for ACSM activities in all the ten districts and these included a vehicle for every district. In addition, ACSM plans were developed for all the ten districts. Training of community leaders on TB and HIV and AIDS leaders was done in all the ten districts. Effectiveness ++ Public gatherings to sensitize the communities were held. IEC material was also provided during the public gatherings while part it was also placed within the facilities. The trained community leaders were also able to reach their respective communities. Radios sport were conducted to sensitize the communities on TB and HIV and AIDS issues and media fraternity was capacitated on proper reporting on TB/HIV collaborative actives. Relevance Yes To improve the CDR and the TSR it was essential that communities sensitized. Impact + The good performance in CDR can be attributed to these interventions due to high levels of awareness created through the public gatherings; sensitizations by community leaders and IEC material distributed during the public gatherings have made people to seek health services. Sustainability ± Community participation in TB care and treatment remains one of the key strategies in the NTP strategic Plan and as such the Ministry of Health and its technical partners will continue avail resources for this intervention. The momentum to carry out the ACSM activities at the district level is not certain since the District Health Educators were not absorbed into government following the closure of this grant. Legend No: - Not Clear: ±, Adequate; + Exceptional: ++ Caption: On the left community leaders receiving training on ACSM. On the right Public gathering held by Health Educator 10
During the implementation of this grant districts developed annual ACSM plans which involved all the stakeholders at the district. Thus the grant was able to create capacity at the district for the implementation of the ACSM activities. These plans were not there prior to the implementation of the grant. This can be considered as a big step forward in strengthening ACSM activities at the district level. However since the District Health Educators who were charged with the responsibility of carrying out these activities are not there, implementation of ACSM activities might be compromised. 2.2.5 TB/HIV The implementation of this grant coincided with the implementation of the National TB Strategic TB/HIV Plan 2008-2012 and the grant supported capacity building efforts in the rolling out of TB/HIV collaborative activities in the country. Specifically the grant concentrated on training of the Health Care workers so as to provide them with the required skills to offer TB/HIV services within health facilities. Table 8: TB/HIV Efficiency ++ Health care workers were trained on TB/HIV collaborative activities. Community Health care workers were also trained on TB/HIV collaborative activities Effectiveness ++ These training led to skills development of the health care workers required for the roll out of TB/HIV collaborative activities. Furthermore community health workers were also capacitated on sensitizing the communities about TB/HIV collaborative activities Relevance Yes Supported interventions in the National TB Strategic TB/HIV Plan 2008-2012 Impact + The uptake of TB/HIV collaborative activities has always been on the increase during the implementation of this grant. This is reflected in the coverage of HTC and CPT on TB patients. Performance is improving on ART coverage. Sustainability + The Ministry currently has a number of technical partners providing TA on TB/HIV collaborative activities. Legend No: - Not Clear: ±, Adequate; + Exceptional: ++ Caption: To ensure TB/HIV co-management, the TB clinics offer HIV services while ART clinic also screen their patients for TB. 11
In Lesotho it is reported that the co-infection rate is around 80% and that HIV fuels mortality on TB patients and this can comprise treatment outcomes. As a result it is encouraging that more TB patients are getting tested for HIV. HIV positive TB patients are also provided with CPT and those in need of ART are also put on treatment. The increased coverage implies that the HIV related mortality on TB patients will be reduced TSR will improve. 2.3 Financial Accomplishments The total budget of the grant for the five year period was $5,543,667.31. At the end of the grant period $4,049,413.43 was expended and this translated into 73% of the total budget. The budget and expenditure analysis is first presented in categories Human Resource The main reason for over spending in this category is that salaries of the drivers were reviewed upward and benchmarked against other GF grants. Technical assistance There were no funds allocated for TA in phase 2 resulted in the variance which is over-expenditure has been inherited from phase I of the grant. Training Under spending on the training category was due to the following factors; In phase 1 savings were derived from the trainings on strengthening NTP H.ED, for TB ACSM (MA 2) due to late engagement of staff. Delays were experienced in the training of Journalist on TB and this has resulted in a residual amount for ACSM. Funds for Long-term training for Lab staff were not fully consumed due to unsuccessful academic applications by some of the nominated staff. Savings were also realized on short courses and International TB conferences. Trainings that were planned were postponed due to the DHS carried in 2009.The survey involved majority of HCW and as a result funds were not consumed in totality and some of the postponed trainings were not implemented at all. 12
Some training could not be implemented due to lack of funds from both the PR and the SR and when the funds were available the HCW could not accessible due other priorities by the Ministry such as conducting National Immunization Campaigns on Measles and other diseases. Health Products The main reason for the under spending within the health products category was late deliveries of goods and services such as the consumables and the situation contributed to slow movements of funds. Infrastructure and other equipment Over expenditure under this category was due to the following; Delays in initiation of refurbishment in the two laboratories resulted in increased construction costs which have possibly been minimized if the procurement processes were initiated on time. Part of the expenditure was made to safety cabinets, deep freezers and staining racks and these were inherited from phase I due to late delivery by the vender. Additionally refurbishment of laboratories was inherited from phase I Communication Materials Under spending on the communication materials was attributed to; Delays in engagement of a service provider to implement radio and TV spots meant that savings were realized at end of grant. Production of billboards, posters and leaflets was delayed due to delays in the appointment of service providers and savings were realized as a result. The procurement of referral documents was delayed by the SR from inception and this brought late deliveries of the documents by the service provider. Delays in the production of DVD s for TB educational sessions Monitoring and Evaluation Low expenditure on this category was brought about several factors and these included; During phase I ACSM monitoring by the central and district team were not done and the funds earmarked for the activity were not utilized Funds earmarked for TB operations research were not used since the activity did not take place because of the Drug Resistance Survey (DRS) that was being implemented at the time. And the majority of key personnel responsible for this operational research were engaged in the TB DRS. Budgets meant for conducting supervision of communities by districts were used minimally because district teams already had scheduled visits that are part of the DHMT. Monitoring and evaluation ACSM activities in each community by district health educator and TB coordinator were not conducted due to the NID. Planning and Administration Some of the annual meetings planned for the NTP review could not be carried out due to competing activities at district level and this led to accumulation of unused funds from the grant. 2.4 Overall Programmatic Achievements and Impacts The long term vision of the Global Fund support to recipient countries is to create a long term capacity for countries to manage health and development challenges related to HIV/AIDS, TB and Malaria. In the case of Lesotho credible progress has been made in terms of building this capacity. The country secured two grants, round 2 and 5 before implementing the round 6 grant and as a result the country was in sound footing in terms of building its health systems. Some of the achievements under the round 6 grant are outlined as follows During the implementation of the round 2 TB grant, the Ministry of Health updated the TB policy to include the HIV component and revised the strategic plan accordingly. The round 6 grant came in effect to implement the TB/HIV collaborative activities which were in the strategic plan. As a result the grant has created a solid foundation for TB/HIV collaborative activities in the country. One of the major achievements under the round 6 grant is that, it introduced community interventions that were aimed at empowering communities to take 13
active part in TB care, treatment and support of TB patients. The involvement of community structures as well the ACMS interventions in the TB care were new approaches which the NTP was implementing. There was tremendous capacity created on monitoring and evaluation system for the National TB program initiated under round 2 TB grant. These efforts were further strengthened under the round 6 grant and these included the review of existing data collection tools to incorporate reporting on community based interventions. For example during phase1 of the grant, the village health workers could not report on referrals even though they were carried out. When moving to phase 2, proper data collection tools were developed and Community Health Workers are currently using these tools. There was also the review of existing tools such as the TB register to include data on TB/HIV collaborative activities. The M&E system for TB was improved as result of the grant. The grant has been able to strengthen the laboratory services through supporting microscopy services, refurbishment of some laboratories, and procurement of essential equipment for all the laboratories. This was done to ensure early diagnosis of all TB cases and high quality treatment of all diagnosed cases of TB is provided. Caption: TB testing is now available in all hospital laboratory around the country to ensure timely diagnosis of TB in order to save lives. Chapter 3: Sustainability plan & Lessons learned 3.1 Sustainability Plan The concern of sustainability in relation to TB programmes is delicate one to address for it implies that government with its meager revenue should continue to fund some of the activities considered very important when the grant comes to an end. The grant officially ended on 30th June 2012. It was established that some activities that were initiated and supported under the grant will still require to be carried out post the grant implementation period. These activities are related to sustainability of human resource, (Health Educators, Microscopists), continued support to procure reagents and consumables, and maintenance of equipment, vehicles and furniture procured under the grant. Currently the health educators are no longer in existence as these were not included in the establishment list of the MOH. However with Miscroscopists, these will continue to be supported by other resources from ICAP Programme and R8 TB Phase 2. The MOH has made decision to absorb the cadres by end of R8 TB phase 2 as is regarded as very important to the success of National TB programme. Through recurrent budget and other resources from the Partners such as PIH, the MOH will continue to support procurement of reagents and consumables as well as the Anti TB drugs. Maintenance of highly expensive equipment and maintenance of the refurnished laboratory equipment will continue to be supported under the recurrent budget. The ten vehicles that were procured have all reached their depreciation life span. Most of these vehicles were earmarked to be utilized at district level where the terrain is much harsh. The CCM has pronounced and approved that round 6 assets include these vehicles be officially transferred to the MOH. As a result due to high maintenance costs, the decision was reached that those still existing should be auctioned, and the money to be raised be used to further support NTP Programme. 14
3.2 Lessons Learned The section provides key lessons learned during the grant implementation. The assessment looks at the grant implementation arrangements, partnerships with civil society and private sector, CCM functioning oversight and finally the Global Fund management processes including the working relationship with Global Fund secretariat and LFA. 3.2.1 Grant implementation arrangements The Ministry of Finance was the Principal Recipient of the grant, while the Ministry of Health was the Sub Recipient. Both the PR and SR acquired the relevant experience and capacity when they were implementing both the round 2 and 5 grants as well as the round 6 grant. 3.2.2 Partnerships with donors, civil society, private sector, etc. The World Health Organization is a partner providing the technical and other forms of assistance for a wide range of health related activities in Lesotho, such as capacity building of various areas related to TB matters. The technical assistance can be at management and implementation level. There are other Partners such as CHAL that support the MOH to implement and provide services at district level where MOH has no presence. Other Technical Partners support MOH by providing technical capacity support for some of the Programmes that are being integrated with TB Programme provided below. 15
3.2.3 CCM functioning and oversight challenges The key responsibilities of the LCCM include overseeing the implementation of activities under the Global Fund approved programmes including approving major changes in the implementation of the Global Fund as necessary, evaluating the performance of the Global Fund Programmes and submitting report to the GF for continued funding during the grant period, ensuring linkage and consistency between Global Fund assistance and other resources available in support of National HIV and AIDS and TB programmes, ensuring the participation of all relevant involved in decision making processes and providing information on the Global Fund Grants ; such as call for proposals, decision of the LCCM and approved proposals and implementation of the Global Fund grants to a wide range of stakeholders During the implementation of the grant, the CCM was able to provide the technical support to PR and SR (these included WHO, ICAP, UNICEF, and PIH as Part of CCM). Furthermore the CCM was able to raise alarm to the MOH during the slow implementation of the round 6, and supported the PR when funds were not being released on time from the GF Secretariat. During the CCM meeting when LFA was present, the CCM supported the PR and SR to put forward the challenges that contributed in some instance, stagnant of non disbursement that may have contributed to recommendations that were made but not accurate to the TGF as a result to On Site Data Verification (OSDV) findings at health facilities. CCM received technical support for strengthening its oversight role function. The support was intended to improve the capacity of CCM in implementation of all the grants. The support was targeting the following areas; Setting up the oversight Committee This committee is mandated to provide technical support to the CMM in analyzing the reports from the PR and identify key issues and for each grant and make recommendations to the CCM during the meeting. The analysis of the reports take place prior to meetings and this enables the CCM to focus on issues and recommendations made by the oversight committee in order to improve performance of the grants. The practice is intended to make the CCM meetings to be more efficient and cost effective. Furthermore the oversight plan was also developed and finalized. The plan included the procedures for the PR reporting to the oversight committee, analysis of data received, follow up on issues identified, agreement on recommendations made to be made to the CCM, implementation of the CCM decisions and conducting field visit, the plan also included the role of non-members in the oversight of the grants. Development of Dashboard Tool The tool provides an overview of grants status using a series of easy to interpret charts, graphs and tables. It guides the CCM oversight committee of grant implementation through financial, management and programmatic indicators. Strengthening CCM Operations As part of streamlining its functions for efficiency in operations, the CCM monthly meetings were replaced with quarterly meetings. This was done the make time for the committee to carry out its tasks and make it easier for most of the CCM members to attend the meetings. In addition four committees were established and formally constituted and the TOR for each committee was developed together with the workplan. These committees are executive committee, proposal development committee, communication committee, and oversight committee. Each committee presents its report and recommendations for discussion during the CCM quarterly meetings. Strengthening CCM communication and stakeholder participation The CCM was supported to develop plan that included steps to strengthen the CCM engagement with its constituencies. The plan was developed focusing on information sharing, enhancing transparency in decision making and constituency. The plan was developed because did not have mechanisms to in place to share information with its stakeholders to enable its constituencies to participate in CCM activities. Development of CCM Strategic and Operational Plans Prior to the support the CCM has been operating without a workplan and it lacked a strategic focus on its long term goals. It also lacked annual workplan to guide it activities. The CCM was therefore supported to develop both the CCM strategic plan 2012-2014 and the CCM operational plan 2012-2013. These plans are intended to guide the CCM in capacity development in the medium term. The CCM s main challenge was related to commitment of the members to attend committees meetings 3.2.4 Global Fund grant management process including working relationships with Global Fund Secretariat and LFA. Finance The PR was expected to demonstrate capacity in terms of processes between the PR and Project accounting Unit to perform financial reporting, budget management and 16
disbursement requests. These processes were done by both the PR and SR and approved by the Global Fund. The financial Management capacity of the both the PR and SR was improved as result of experience acquired during the implementation both round 2 & 5 grants. However as a result of increasing number of grants under the Ministry of Finance as the PR a decision was reached that the finance section of the PR needs further strengthening. A technical assistance and additional staff will be engaged to improve efficiency in the section. Monitoring and evaluation During the implementation of this grant the M&E system for the NTP grant was strengthened. A time bound action plan was developed for the enhancement of the Monitoring and Evaluation capacity of the NTP program. The plan outlined the gaps that were identified in the monitoring evaluation system of the NTP program. The gaps identified included non-availability of data collection tools for reporting on some indicators under the grant. The tools were developed and are now in use. There was also the review of existing tools such as the TB register to include data on TB/HIV collaborative activities. In addition the NTP was to ensure that the electronic TB register was functional and facilities capture data using the register. During the implementation of the grant periodic OSDV was implemented to assess quality of reported results. The OSDV conducted led to the review of the indicators and targets related to TB/HIV collaborative activities. The review led reporting based on coverage indicators using proportions instead of absolute numbers which did not have any useful meaning interms of the program achievements. Procurement The procurement unit from the Ministry of Health and NDSO were also assessed and found capable to support the procurement of goods and services for both nonhealth products, health products and medicines products respectively. Chapter 4: Conclusion and Recommendations 4.1 Conclusion As has been observed and discussed from the previous chapters, it can be concluded that Case Detection Rate (CDR) has continued to improve and perform above the WHO minimum requirement, which means the country is performing well on this indicator. The uptake of TB/HIV collaborative activities gained momentum as witnessed by the current performance on TB/HIV indicators. Despite the good results mentioned above Treatment Success Rate (TSR) has over the past five years continued to fall behind WHO recommended minimum level of performance and this calls for a review of the current strategies. The implication is that the country will still require financial support to implement strategies that will improve the treatment outcomes. Through the R8TB Phase 2, major activities that include support to Community health workers interventions have been included whereby issues related to defaulters that may lead to high mortality can be reduced. Absorptive capacity of finance earmarked for this grant was achieved at 73%. It is imperative to improve the absorption of funds to ensure that Lesotho can continue to receive substantial financial support for interventions that would enable the country to achieve and surpass WHO target of Treatment success rate, therefore reduced TB Patient mortality rate in future. Highly skilled and motivated workforce is required to support the TB program and improve the Country s performance. On conclusion it has to be acknowledged that the Global Fund investments have tremendously built the health system in Lesotho in financial capacity, M&E capacity and programme management capacity, nonetheless more efforts are still needed to be put in place. 4.2 Recommendations To improve treatment outcomes, the country with the assistance of development partners need to direct efforts to high impact interventions. Sustainability of the interventions initiated under external support will always pose a challenge to government since the government budget cannot always meet the donor resources when the donor phases out. As such future proposals should attempt to include the issue of sustainability during the proposal development phase to avoid future challenges in service delivery. There is urgent need to support and ensure that annually Health resource mapping is conducted so as to reduce duplication of efforts by various MOH partners. As such coordination and transparent information is required from the Donor community to avoid duplication of efforts, which in most instances lead to low absorptive of funds. 17
ANNEX ONE: TB Programme achievements in pictures Microscopy Equipment procured for the seventeen(17) laboratories for microscopy services Teaching microscopes in Mafeteng hospital lab Above microscopists deployed under R6 TB grant and procured microscopes to improve diagnosis. 18
Laboratory Equipment Procured under the R6 Grant Above is incubator on the left and lab oven on the right while below is the centrifuge. All are lab equipment for TB lab procured under round 6 TB grant Caption: Above in green color is the lab oven also procured under grant to improve diagnosis 19
Some of the safety cabinets and Lab chairs procured and distributed to health facilities Some of the office furniture procured for District Health Educators coordinating ACSM activities in all districts The Mafeteng hospital Laboratory was extended to include TB laboratory and refurbished under this grant (Outside and inside structures) 20
Part of the IEC material procured under the grant Paray Hospital Laboratory Extension (inside the laboratory) 21
Six (6) of the ten (10) Vehicles procured under the grant Extension of Laboratory in Quthing Hospital 22
Compiled by Global Fund Coordinating Unit (GFCU) Ministry of Finance 4th Floor Matekane Group of Companies (MGC) Office Park P.O. Box 395, Maseru 100, Lesotho Telephone +266 22324023 Fax +266 22324352 Web address: www.gfcu.org.ls Email: info@gfcu.org.ls