Southern Africa Tuberculosis and Health Systems Support Project

1. Southern Africa Tuberculosis and Health Systems Support Project Health, Nutrition & Population Global Practice The World Bank 8 Dec. 2016

2. Objectives & Structure • Informative • summarize the technical design and implementation arrangements • Explorative • opportunities for strategic partnerships and innovation • Practical • discussion on implementation issues (Governments, Regional Organizations, Bank and Partners)

3. MDG6 TB target achieved REVERSED 47%DROP IN TB MORTALITY TB EPIDEMIC Incidence rate Mortality Falling 1.4% per year (2000-2015). 18% drop since 2000 49 million lives saved between 2000 and 2015 Target 47% decline since 1990 But huge burden of deaths and suffering remains. 10.4 million people fell ill with TB in 2015, and there were 1.8 million deaths

4. Highest TB/HIV Co-infection Rates:50-77%

5. Increased Risks of MDR-TB: Trans-boundary Effects, Costly and Higher Treatment Failure Rates

6. Underlying Issues in SADC – High Burden of TB • High burden of HIV/AIDS • Underlying health systems weaknesses • TB response, detection, and monitoring constrained by: • weaknesses in occupational and mine-health regulations, unenforcedlegislation, • poorly standardized treatment protocols, • weak diagnosticcapacity and services • unavailability of skilled human resources for health (HRH), and inadequate financial resources. • Country TB control efforts – limited effectiveness in addressing high risk groups, i.e. mining communities • Complex relationship between mining, poverty and disease burden in SADC • High burden of TB amongst mineworkers • Migratory nature of mineworkers and resultant transmission of TB to families and communities around mines and labor sending areas

7. Summary of Proposed Approach

8. Main Rationale for Regional Approach • Word Bank’s commitment to supporting countries in the sub-region to tackle TB while strengthening critical dimensions of health systems. • POLICY HARMONIZATION: High levels of population mobility, porous borders, and regional and global communicable disease threats call for a highly coordinated and harmonized action • MARKET FAILURES & SPILL OVER EFFECTS:A coordinated regional approach is critical for activities with high spillover effects where individual countries may not have the incentives and resources to invest OR if one country does not manage a well, risks for neighboring countries is heightened • ECONOMIES OF SCALE: There is a potential to reap economies of scale through specialization, rather than developing all areas of expertise in each country • REGIONAL STEWARDSHIP: Opportunity to support regional institutions to synchronize policies and strategies; define a regional vision; and serve as a platform for knowledge generation and cross country learning

9. A new era with new ambitions and a paradigm shift UN Sustainable Development Goals: 2016 – 2030 17 goals and 169 targets

10. SDG 3 and its 13 targets by 2030 3.3 End the epidemics of AIDS, tuberculosis, malaria & neglected tropical diseases and combat hepatitis, water-borne and other communicable diseases 3.1 Reduce Maternal mortality 3.2 Reduce child and neonatal mortality 3.3 End the epidemics of AIDS, tuberculosis, malaria &neglected tropical diseases and combat hepatitis, water-borne and other communicable diseases 3.4 Reduce mortality due to NCD and improve mental health 3.5 Strengthen Prevention and treatment of substance abuse (narcotics, alcohol) 3.6 Reduce Mortality due to road traffic injuries 3.7 Universal access to sexual and reproductive health-care services 3.8 Achieve universal health coverage 3.9 Reduce deaths and illness due to pollution and contamination 3.a Strengthen implementation FCTC (tobacco) 3.b Access to affordable essential medicines and technologies 3.c Increased health financing and health workforce in developing countries 3.d Enhance capacity for early warning, risk reduction and management of national and global health risks

11. Moving from halting TB to ending TBby 2030 Global commitment to End TB SDG Target 3.3 – BY 2030 end the TBepidemic

12. Innovations and Research are critical to break the trajectory of the TB epidemic • Better diagnostics, including new point-of care tests; • Safer, easier and shorter treatment regimens for disease andlatent TB infection; • Effective pre- and post-exposure vaccines. • All technological and system innovations possible

13. ProposedTechnical Approach • Alignment with post-2015 global strategy for TB prevention, care and control • Broad areas • Strengthening of integrated patient care and prevention • Implementation of regional protocols and expanding supporting systems • Examples of Innovations and research • Mobile & electronic platforms e.g. use of mobile phones, management information systems, electronic medical records, etc. • Performance-based contracting (PBC) of non-state actors • Private sector focused models (win-win scenarios)

14. Builds on & Compliments Country and Regional Efforts • Government Programs (TB, Mining & Labor) • Bank Country Specific and Regional Investments • Development Grant Fund – Catalytic US$ 2 million • DFID Trust Fund US$ 4 million • Bank Projects for Country Specific Issues • Global Fund country and regional • Global Fund Grant for TB in the Mines 10 countries –US$ 30 million • Global Fund Grant for Labs – 18 countries US$ 6 million • Bilateral Programs

15. Summary of Design – Overall Objective Project Development Objectives: Improve coverage and quality of key TB control and occupational lung disease services in targeted geographic areas of the four participating countries; and Strengthen regional capacity to manage the burden of TB and occupational diseases.

16. Targeted Approach • Key criteria based on: • Geographic characteristics (mining/peri-mining) • A high burden of TB • Border regions/districts • Transportation corridors • High incidence of poverty & TB (where data available)

17. Overview – Component 1: Innovative Prevention, Detection and Treatment of TB • Subcomponent 1.1: Enhance case detection and treatment success • Demand side interventions – community based targeting households, miners, caregivers • Improve the clinical quality and ensure International Standards for TB care across the four countries • Support to TB and MDR-TB patients e.g. nutrition, Anti-TB drugs • Performance based contracting (innovative TB interventions e.g. specimen transportation, results based funding for NGOs)

18. Component 1 continued… • Sub Component 1.2: Rolling out a standardized package of occupational health services and mining safety standards across the four countries • Strengthen government agencies capacity for mine safety – inspections on mine dust levels • Expanding periodic screening and referral of occupational lung diseases and other diseases e.g. Diabetes • Develop/strengthen occupational health databases and electronic record systems

19. Component 2: Regional Capacity for Disease Surveillance, Diagnostics, and Management of TB and Occupational Lung Diseases • Sub-component 2.1: Improving quality and availability of human resources in the targeted areas • Development of a skilled health workforce based on a regionally defined curricula, mentoring and knowledge sharing in TB, mine health regulation/Occupational services and disease surveillance • Address specific skills gaps i.e. co-management of HIV-TB; MDR-TB; disease surveillance; occupational health; laboratory and diagnostics • Support pre and in-service training, inter country exchanges, on-the-job technical mentorships

20. Component 2: Continued… • Sub-component 2:2 : Strengthening diagnostic capacity and disease surveillance • Partner with CDC, WHO and ASLM – Scaling up of Strengthening Lab Management Towards Accreditation (SLMTA) & SLIPTA • Rolling out newer and more accurate diagnostic technologies • Develop a mechanism for intelligence sharing on disease threats among participating countries • Networking of National TB laboratories and linkage to Supranational (e.g. Uganda SRL)and Regional Labs • Establish joint cross border committees for joint outbreak investigations and public health events

21. Component 2 continued… • Sub-component 2.3: Strengthening mine health regulation • Update or draft occupational and health safety legislation, guidelines and policies • Developing IT systems for compliance monitoring and mine health surveillance • Support mine health equipment and training • Developing/updating regional best practices guidelines on regulation and clear standards REL in large and small-scale mines • Capacity building of regulatory institutions to enforce mine health regulations

22. Component 3: Regional Learning and Innovation and Project Management • Promotes regional innovation through sharing of knowledge, evidence from interventions implemented under components and 1 and 2, and activities supported under regional centers for excellence. • regional baseline assessment reports that bring evidence to better define the context, and inform policy and project interventions; • in-depth case studies capturing the mechanism and outputs of innovations funded by the project; • south-south learning exchanges between policy makers and practitioners from the four countries and between them and other parts of the developing world with successes in TB, such as Peru; • rigorous process evaluation of interventions, subject to the feasibility of the design of the interventions. • a joint annual review and planning, which brings together the four project countries, will be undertaken and used as a platform to strengthen cross-country learning and promote innovative approaches.

23. Component 3 continued… • Sub-component 3.1: Operational research and knowledge sharing: Priority Research topics • Impact evaluation of new diagnostics tools on health outcomes • Mapping of mining activities within the participating countries • In-depth case studies capturing the mechanism and effects of innovations funded by the project • South–South learning exchanges between policy makers and practitioners from the participating countries and between them and other parts of the developing world with successes in TB, such as Peru

24. Component 3: Continued Sub-component 3.2 Centers for Excellence in TB and Occupational Lung Disease Control Lesotho - community-based management of TB (use of digital mobile x-rays) Malawi- community TB care &integrated disease surveillance Mozambique - MDR-TB &childhood TB management Zambia- occupational health and safety.

25. Communities of Practice (CoP) • Five key areas: • Economics of TB control and sustainable financing • Service delivery: continuum of TB care across and within national boundaries • Research, and monitoring and evaluation (M&E) • Mine health regulation and occupational health • Diagnostics and surveillance of diseases

26. Example: Thematic Responsibilities for Learning and Knowledge Sharing UGANDA TANZANIA Lab Training Networking KENYA O.R. Surveillance ECSA In collaboration with EAC RWANDA ICT/MDR-TB PBF (jointly with Burundi) Empowering clients through access to knowledge

27. Component 3: Continued • Sub-component 3.3 Regional coordination, policy advocacy and harmonization • Support ECSA-HC and NEPAD to undertake regional activities – economies of scale, regional learning and knowledge exchange • Roles clearly defined • SADC coordination

28. Regional Advisory Committee (RAC) Southern Africa TBHSS Project To bring together the stakeholders working on the regional project to • provide strategic guidance and oversight functions • review implementation progress • strengthen the working relationships and partnerships opportunities in order to achieve the expected deliverables of the project • ensure coordination with other key initiatives

29. Membership • Permanent/Principal Secretaries of Health • Technical Departments Representatives (2) Implementing Ministries (3) • 1 representative from each MOF Ministries of Finance • Zambia - Chamber of Mines • Lesotho - Association of Miners • Mozambique - NGOs/Civil Society • Malawi - Labor Union • Research Institution Non-State Actors • 1 Global Fund Regional Coordinating Mechanism • 1 member from SADC • Global Expert in Expert in TB control • Technical Partners – CDC; WHO? Other representatives (Ex officio) Donor (Ex officio) • World Bank Strategic partner/country representative • Brazil Regional Coordinating Organizations • ECSA-HC • NEPAD Southern Africa TBHSS Project

30. Regional Advisory Committee (RAC) responsibilities Southern Africa TBHSS Project Convene stakeholders working to: • Endorse regional work plans and deliverables and inter-ministerial NTC • Review implementation progress • Review communities of practice annual work plans • Provide strategic guidance and oversight • Explore opportunities for new partnerships and advocacy for the project • Ensure coordination and alignment with other initiatives (ie the GF initiatives) • Follow up on Key research findings

31. National Technical Committees (NTC) • At country level the Inter ministerial NTC as main oversight governance committee • Composed of implementing ministries, partners and private associations (country specific) • Responsible for reviewing and approving consolidated work plans and budgets • the primary vehicle to coordinate stakeholder engagement and dialogue with regards to the project. • Platform for partners to report on experiences and lessons and to coordinate future interventions(TB, OSH, Lab, Mines etc)

32. Thank You!