J.18_National_Tuberculosis_Strategic_Plan_(2015-2019).pdf

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National Tuberculosis Strategic Plan

(2015 - 2019)

THE KINGDOM OF SWAZILAND

MINISTRY OF HEALTH

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FOREWORD

Since the declaration of TB as a global emergency by the World Health Organisation (WHO) in 1993, worldwide efforts to fight the disease have intensified considerably. In Swaziland, the escalation of the TB epidemic has been linked with the HIV prevalence in the general population. This TB/HIV co-epidemic being experienced by the country is mainly affecting the sexually and economically productive age group hence it poses a formidable threat to the country's socio-economic development.

Since the declaration of TB as an emergency in the Kingdom, the rising notification of TB cases in Swaziland has been halted through increased investments in TB control by the national government and partners.

However, despite the aforementioned gains, Swaziland remains the country with the highest burden of TB per capita in the world. Furthermore, the numbers of notified Multi-Drug Resistant (MDR) TB cases continue to increase every year. Other challenges still being faced by the country's TB control efforts also include: high HIV co-infection rate among TB patients (80%), non-communicable co-morbid conditions especially diabetes mellitus, social determinants of the disease, and sub-optimal detection and enrolment into treatment of childhood TB cases. These challenges and other key programmatic gaps need to be comprehensively addressed to find all the cases of TB that are missed every year in our current case finding strategy and to ensure effective support systems for patients on TB treatment.

The resolve of the Government of Swaziland to eliminate TB as a public health challenge has culminated in the:

strengthening of the National TB Control Programme (NTCP) at both national and regional levels, establishment of a National TB Hospital to ensure a coordinated response to both drug susceptible (DS) and drug resistant (DR) TB, and increased collaboration between the TB and HIV programmes through the National TB/HIV Coordination Committee

(TB/HIV NCC).

I present to the nation, a new TB strategic plan (2015 - 2019) which builds on a largely successful predecessor NSP (2010 - 2014). This National Strategic Plan (2015 - 2019) is intended to effectively guide all tuberculosis control interventions across all sectors in the country. This document has been developed through robustly consultative and validation processes which were representatively inclusive of all relevant stakeholders. Furthermore, this document is fully aligned with the Post-2015 Global TB Control Strategy, National Health Policy (2007), National Health Sector Strategic Plan and the findings of the post-term evaluation of the predecessor strategic plan. Thus, innovative and purposeful implementation of this strategic plan by all sectors will ensure that all TB preventive and care services rendered in the kingdom are: universally accessible, affordable, equitable, ethical, patient-centred, appropriately prioritising all key populations, and supported by relevant bold policies.

I would like to reiterate that the Ministry of Health considers TB control a priority and is strongly committed to the fight against TB, and will continue to provide stewardship to facilitate the achievement of national and global targets for TB control.

Dr. Simon Zwane

Principal Secretary - Ministry of Health iii

Acknowledgements

The development of theseNSP was led by the Swaziland Nation Tuberculosis Control Program and technically supported by our partners. The Ministry of health acknowledge the immense technical contribution of World Health Organisation (WHO); US president’s Emergency Plan for AIDS Relief (PEPFAR) through Univercity Research Co. LLC (URC); MSH: Medicins Sans Frontiers (MSF); Baylor College of Medicine.

The efforts and unparalleled commitment demonstrated by the National TB Technical Working Group members towards accomplishment of this important task.

We appreciate the inputs of our external peer reviewers to the final draft of the NSP who contributed to its improved quality.

Finally, we are grateful to WHO for supporting the printing of this NSP.

Dr Samuel Magagula

Director of Health Services

TABLE OF CONTENTS

5.1.2 Strengthen contact investigation in communities

5.1.3 Implement intensified TB case finding in all healthcare settings

5.1.4 Strengthen and expand TB Laboratory network

5.1.5 Laboratory quality assurance and accreditation

5.1.6 Strengthen referral and linkage-to-care of TB patients

5.1.7 Strengthen the integration of care for childhood TB with other child care services

5.2 Objective 2: Increase treatment success rate from 76% to 90% by 2019

5.2.1 Expanding access to TB treatment

5.2.2 Strengthen treatment adherence and support

5.2.3 Engagement of communities, civil society organizations, public and private care provider

5.2.4 Ensure an uninterrupted supply of 1st line Anti - TB medicines to treat all diagnosed patients, including adverse events

5.3 Objective 3: To implement and expand country-wide collaborative TB/HIV activities and management of co-morbidities by 2019

Rationale

5.3.1 Strengthen the delivery mechanism for integrated TB and HIV services

5.3.2 Reduce the burden of TB in people living with HIV (The three I's for TB/HIV)

5.3.3 Reduce the burden of HIV in patients with presumptive and confirmed TB

5.3.4 Ensure proper management of comorbidities

5.3.5 Decentralize TB initiation and follow up to lower level clinics including Public Health Units (PHUs)

5.4 Objective 4: To reduce the MDR-TB prevalence rate amongst new TB cases from 7.7% in 2009 to less than 5% by 2019

5.4.1 Preventing the development and transmission of drug-resistant TB strains

5.4.2 Strengthen case finding for MDR-TB amongst high risk populations

5.4.3 Increase access to DR-TB treatment initiation

5.4.4 Ensure timely enrolment of all bacteriologically confirmed and presumed MDR-TB patients on treatment

5.4.5 Strengthen case management

5.4.6 Strengthen community DR-TB management, care and support

5.4.7 Establish a Palliative Care and support package for DR-TB Patients

5.4.8 Strengthen Research to improve MDR TB management

5.4.9 Improve Gender equity/sensitivity in MDR-TB Care and Management

5.4.10 Advocate for supportive public health policies and legislations

5.4.11 mHealth

5.5 Objective 5: To strengthen the NTCP national TB response management capacity to effectively coordinate and evaluate TB prevention, treatment and care interventions

5.5.1 Strengthen program management and coordination

5.5.2 Health Systems Strengthening

6 Monitoring and Evaluation

6.1.1 TB M&E system

6.1.2 M&E framework

6.1.3 M&E indicators

6.1.4 Monitoring tools

7 Implementing the NTP strategy (Core Activity Plan)

1.3 Strengthen intensified TB case finding in all healthcare settings

1.4. Strengthen and expand TB Laboratory network

3.1. Strengthen the delivery mechanism of integrated TB and HIV services

8 Technical Assistance plan (Programmatic Gap Analysis)

9 References iv v

LIST OF ACRONYMS AND ABBREVIATIONS

ACSM

Advocacy, Communication and Social Mobilization

AIDS

Acquired Immune Deficiency Syndrome

ART

Antiretroviral therapy

ARV

Antiretroviral drug

CBO

Community Based Organization

CHAI

Clinton Health Access Initiative

CHC

Community Health Centre

CHW

Community Health Worker

CDC

Centre for Disease Control

CMS

Central Medical Stores

COE

Centre of Excellence

CPT

Cotrimoxazole preventive therapy

C&T

Counselling and Testing

CSO

Civil Society Organization

CSS

Community Systems Strengthening

DST

Drug Sensitivity Testing

DTC

Diagnostic Testing and Counselling

DOTS

Directly -Observed Treatment, Short course

DRS

Drug resistance survey

EQA

External Quality Assurance

FAST

Finding cases Actively, Separating safely, and Treating appropriately and promptly

FIND

Foundation for Innovative Novel Diagnostics

GDF

Global Drug Facility

GFATM

Global Fund to fight AIDS, Tuberculosis and Malaria

GLC

Green Light Committee

HCW

Health care worker

HR

Human Resources

HRD

Human Resource Development

HSS

Health Systems Strengthening

HIV

Human Immunodeficiency Virus

HMIS

Health Management Information System

HTC

HIV testing and counselling

IEC

Information, Education and Communication

IPT

Isoniazid Preventive Therapy

ISTC

International Standards for

TB Care

IUATLD

International Union against Tuberculosis and Lung Disease

MDG

Millennium Development Goals

MDR -TB

Multidrug -Resistant Tuberculosis

M&E

Monitoring and Evaluation

MOHSW

Ministry of Health and Social Welfare

MOF

Ministry Of Finance

MSM Men who have Sex with Men

NCC National Coordination Committee for TB/HIV Collaborative Activities

NGO Non-Governmental Organization

NTCP National Tuberculosis Control Programme

NLS National Laboratory Services

NRL National Reference Laboratory

OPD Out-patient department

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

PHC Primary Health Care vi

PHU Public Health Unit PLHIV People Living With HIV/AIDS PMTCT Prevention of Mother-To-Child Transmission PPM Private-Public Mix QA Quality Assurance R&R Recording and Reporting STI Sexually Transmitted Infections SNAP Swaziland National AIDS Programme

SNRL

Supranational Reference Laboratory

TBCAP

Tuberculosis Control Assistance Program

TB

Tuberculosis

UNAIDS

Joint United Nations Programme on HIV/AIDS

USAID

United States Agency for International Development

URC

University Research Co., LLC

VCT

Voluntary Counselling and Testing

WHO

World Health Organization

XDR-TB

Extensively Drug-Resistant Tuberculosis vii

EXECUTIVE SUMMARY

This TB National Strategic Plan (TB NSP) 2015-2019 is a successor plan for the 2010-2014, TB NSP. The Goal of the 2015-2019 TB National Strategic Plan (TB NSP) is to achieve a 35% reduction of TB prevalence rate by 2019 to 907/100,000 of 2013. The NSP is based on five objectives for the next five years as follows:

1. To increase TB case detection rates from 46% in 2013 to 70% in 2017 and 80% by 2019

2. To increase TB treatment success rates for all bacteriologically confirmed cases from 72.9% in 2013 to 90% by 2019

3. To implement and expand country-wide collaborative TB/HIV activities and management of co-morbidities by 2019

4. To provide treatment and support to all drug-resistant TB cases and reduce the MDR-TB prevalence rate amongst new TB cases to less than 5% by 2019

5. To strengthen the capacity of the National Tuberculosis Control Program to effectively implement, coordinate and evaluate TB prevention, treatment and care interventions

The following impact measurement targets have been identified:

1. Reduction of TB prevalence by 35%.

2. Reduction of mortality among TB/HIV co-infected patients to below 5% by 2019.

3. Reduction of MDR-TB prevalence among new TB cases to below 5%.

Targets at outcome level:

1. Diagnosis and enrollment on TB treatment of at least 52 800 TB cases by 2019

2. Provision of TB treatment to all diagnosed cases and achievement of at least 90% treatment success rate by 2019

3. Reduction of the mortality rate among TB/HIV co-infected patients from 10% to below 5% by 2019

4. Reduction of MDR-TB prevalence among new TB cases to below 5% by 2019

5. Reduction by 50% of affected families facing catastrophic costs due to TB.

6. To have reached a total of 145 BMUs providing full TB services, to include coverage of all PMTCT sites

7. Research capacity strengthening within the NTCP to support evidence-based programmatic decision-making

Milestones to be achieved by 2017:

1. Reduction of TB prevalence by 15%

2. Treatment success rate of 80% among all TB cases

3. Reduction of mortality among TB/HIV co-infected patients by 5%

4. Reduction of MDR-TB prevalence among new cases to 5%

5. At least 125 BMUs established

6. Implementation and expansion of collaborative TB/HIV activities and management of co-morbidities to

80% of health facilities

7. Results of TB Drug Resistance Survey, TB prevalence studies and Paediatric inventory study must be disseminated to all stakeholders and scientific community.

8. Completion of clinical trial on short-course MDR-TB treatment regimen and dissemination of study findings

9. To have conducted baseline studies such as cost-effectiveness analysis of new interceptions, community-based participatory research, determination of catastrophic costs and out-of-pocket costs related to accessing TB services viii

STAKEHOLDERS DECLARATION

Declaration of Stakeholder Commitment towards supporting the implementation of the NTCP Strategic Plan 2015 - 2019.

We, as the stakeholders involved in tuberculosis control in Swaziland, pledge and commit to achieving zero TB deaths, zero new TB infections, and zero TB discrimination and stigma, because:

1. TB is preventable and curable.

2. In Swaziland, the main drivers of the TB epidemic are delayed health seeking behavior, poverty, poor living conditions, TB/HIV co-infection, limited contact investigation, etc.

3. The following gains were achieved during the outgoing NSP:

i. decentralization of TB services

ii. integration of TB services into other healthcare services,

iii. improved TB diagnostics using new technologies,

iv. improved case notification rates and treatment outcomes

4. Swaziland has the potential to reach the goal of zero TB deaths, zero new TB infections, and zero TB discrimination and stigma, through joint collaborative efforts.

We are committed to working with Swaziland Government, the Ministry of Health, National Tuberculosis Control Programme (NTCP) and partners to implement the NTCP Strategic Plan 2015 - 2019 to achieve increased TB awareness, prevention, case notification, timely enrollment on treatment and proper management. Targeting the most-at-risk populations (pediatric, miners, inmates, PLHIV and chronically ill patients) to increase case finding. We also pledge to support all efforts towards ensuring availability of TB medicines and supplies, improved patient treatment support by collaborating with the NTCP and health facilities at community levels.

With the above mentioned efforts implemented towards reducing the TB prevalence by at least 35% by 2019 and 50% by 2022, we envisage sustainable reductions in new TB infections and deaths in both adults and children with the goal of zero new TB infections and deaths.

We view the following elements as critical to achieving our goal:

I. Political Will and Commitment by Government and Communities.

II. Active Case Finding and Control of TB Transmission.

III. Family- and Community-Centered Care and Preventive Therapy.

IV. Intensify TB Prevention, Care, and Treatment for the most-at-risk population.

Swaziland is a kingdom located in Southern Africa and is bordered by South Africa and Mozambique in the eastern part. Swaziland has just 17,300 square kilometers of land (157th in the world), with an estimated 2014 population of 1,106,000-1,250,000 (CSO, 2010). The country is divided into four administrative regions -: Hhohho, Lubombo, Manzini and Shiselweni, and the regions are further subdivided into 55 Tinkhundla (constituencies), within which 369 chiefdoms are overseen by chiefs appointed by the king.

Demography According to the 2007 population census, the Swazi population comprises of 53% women and 47% men, with 44% of the population being under 15 years and 46% in the 15-49 years age . The estimated population growth rate is 3.8 (CSO, 2008). Residents of Swaziland are homogeneous in their language, culture and tradition. They speak either SiSwati, or siSwati and English which are considered official languages. While the Swazi have traditionally been farmers and herders, many now work in government, the urban economy, and even in the mines in South Africa.

Approximately 79% of Swazis live in rural areas and depend on subsistence farming for their livelihood, (CSO, 2008).

Economy Swaziland is categorized as a lower middle income country, with a total GDP of $3.747 billion and public spending on health estimated at 4% (UNICEF, 2011). Approximately 70% of the population are living under the poverty line, and the reported poverty index is 0.086 (UNDP, 2010).

1.1 Health Indicators

INTRODUCTION

Indicator name Indicator Score Data Source and Year

Birth rate 35 per 100,000 UNICEF, 2011

Death rate 4 per 100,000 UNICEF, 2011

Infant Mortality Rate (IMR) 104 per 10,00 UNICEF, 2011

Maternal Mortality Rate (MMR) 320 per 100,000 UNICEF, 2011

Life expectancy 45.3 years WHO 2012

Road Traffic Accidents 3% 2011

Tuberculosis 3% WHO

HIV/AIDS death rate 855/100,000 WHO, 2011

HIV prevalence among adults

Among Pregnant Women

26%

41.6%

DHS 2007

ANC Survey 2010

1.2 National Health policy

The Ministry of Health seeks to improve the health of the people of Swaziland by providing preventative services that are high quality, accessible, affordable, equitable and socially acceptable, focused on the top ten causes of death in the country. The objectives of the Swaziland National Health Sector Strategic Plan (SNHSSP 2014-2018) plan are;

? Reduce morbidity, disability and mortality that is due to disease and other social conditions;

? Promote effective allocation and management of health sector resources; and ? Reduce the risk and vulnerability of the country's population to social welfare problems as well as the impact thereof.

The NHSSP II draws from the National Development Strategy and the National Health Policy, which are informed by the global and countrywide health aspirations. It defines key strategic focus and interventions needed to be implemented in the medium-term, to contribute to these overall policy aspirations. The NHSSP II shall be implemented in a number of ways:

- Through programme or system-specific service and investment plans, which elaborate key services or investments that are focused on a given program area that need to be attained.

- Through guidance to the budgeting process, to highlight key investments that need to be considered in each budgeting period.

- Through annual operational plans, which define the activities aimed towards given NHSSP II strategies that will be implemented with available funds.

1.3 Organization of Health Sector

Based on the Primary Health Care strategy and concept, the Health Sector service delivery system is loosely organized in a four-tier system comprising of three national referral hospitals, five regional hospitals, primary health care facilities ( health centers, public health units and clinics with and without maternity, and community based care, RHM's, faith-based health care providers, TBA's, volunteers and traditional practitioners). It is at the clinics and Public Health Units that the health service delivery interfaces with the community.

Services provided in the health sector include preventive, curative and rehabilitative services. Allopathic medicine is the cornerstone of the health sector services delivery, though clients also utilize traditional and/or faith based practitioners for different ailments.

1.4 Health Status

Both communicable and non-communicable diseases continue to be a major challenge for the country. According to Health Statistics Reports, upper respiratory conditions are by far the leading outpatient conditions. The burden of communicable diseases is similarly reflected in the leading causes of inpatient morbidity and mortality, with AIDS and TB together accounting for admissions and a third of deaths. Others are gastro-enteritis, colitis and pneumonia. The most cited reasons for admission include pulmonary tuberculosis, malaria, gastro-enteritis, colitis and pneumonia.

On the other hand diabetes mellitus, a non-communicable disease, was reportedly among the top ten (10) leading cause of inpatient admission in 2009 (HMIS Report, 2009). Others that have added in the burden include cancers, cardio-vascular diseases, nutritional conditions and injuries or trauma (Essential Health Care Package, 2010).

2 SITUATIONAL ANALYSIS OF TB

Swaziland has one of the highest per capita burdens of TB globally, with an estimated TB incidence of 1,349 per 100,000 population, a prevalence of 907 per 100,000 population, and a mortality of 63 per 100,000 population.

Swaziland also has one of the highest HIV per capita burden in the world and 77% of the TB patients are also co-infected with HIV co-infection (WHO Global Tuberculosis Report, 2013). Since 1990, TB cases have increased by more than six times leveling off in 2009/2010. TB was declared an emergency in Swaziland in 2010. However, since 2010, the notification rates for drug susceptible TB, are on the decline while the number of multi-drug resistant TB is on the increase.

Currently, there are an estimated 6,000 Swazi miners in South Africa and about 22,000 ex-miners who were working in the mining sector. Recent data show that among 109 mapped miners and ex-miners, 53% had positive pulmonary TB screening results. Confirmed TB cases including MDR TB were 32% of all suspected cases. (Implementing the harmonized framework on TB in the mining sector: Swaziland will join forces with the SADC countries in addressing the burden of TB in the mining sector as a signatory to the SADC declaration on TB in the mining sector.

Figure 1: Trends in TB Case Notification rates for all forms of TB period

2008 2009 2010 2011 2012 2013

National 9656 11032 11057 9183 7739 6665

Shiselweni 2249 2700 2457 1728 1260 873

Manzini 2949 3259 3860 3580 3151 2772

Lubombo 1975 1887 1801 1336 1344 1236

Hhohho 2483 3186 2939 2539 1984 1784

10000

15000

20000

25000

Figure 1, above, describes the TB notification trends for new and relapse TB cases from 2008 to 2013 by region. In line with the declining total notifications the relapse cases have been decreasing also in the last three years as have so were the new TB cases. This points to a maturing TB epidemic in Swaziland and emphasizes the need for a prevalence survey to accurately determine the burden of TB in the country.

Figure 2, below presents HIV testing results and uptake of ART by TB patients. HTC uptake by TB patients has risen from 86 percent in 2010 to 96 percent in 2013. At the end of 2013 a total of 3,544 (75%) HIV positive TB patients were enrolled on ART. The ART gap has been narrowing over the past few years, in 2010, only 35 percent of HIV positive TB patients were initiated on ART.

Figure 2: TB/HIV collaborative services, 2010-2013

Figure 3: TB Treatment success rates, 2010-2013

Figure 3, above present treatment outcome s for TB patients at the end of 2013: among New Sputum Smear positive cases, the treatment success rate rose from 69 percent in 2010 to 76 percent in 2013. The treatment success rate for all forms of TB rose from 66 percent in 2010 to 72 percent in 2013. Whilst among re-treatment cases, the treatment success rate rose from 51 percent in 2010 to 59 percent in 2013.

Drug-Resistant TB According to the previous Drug Resistance Survey conducted in 2009 (DR survey 2009), the DR-TB incidence rates are 7.7% among new cases and 33.7% among re-treatment cases. Drug Resistant TB cases are reported from the national reference laboratory, as case detection for these strains of TB is done there. In 2013, the laboratory reported receiving and processing 2,043 samples collected from DR-TB suspects in health facilities across the country. About 39% of these samples were found to be culture positive, of which 23% were confirmed MDR-TB cases.

Figure 4: Drug-Resistant TB Case finding, 2013

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Hlathikhulu (15)

Nhlangano (36)

Matsapha (41)

TB Hospital (259)

Hlathikhulu (15)

Matsanjeni (27)

Nhlangano (36)

Piggs Peak (38)

Matsapha (41)

Mankayane (43)

TB Hospital (259)

RR 11 23 26 23 25 27 199

MDR 3 4 6 12 14 14 45

XDR 0 0 0 1 1 0 0

Empiric 1 0 4 2 1 2 15

Approximately 566 drug resistant TB patients were initiated on treatment in 2013 in the seven facilities currently managing DR-TB. Majority of the cases enrolled in 2013 were rifampicin-resistant, an expected trend given the rapid roll-out of GeneXpert in 2012 to over 16 laboratories across the country. The new DR-TB guidelines call for immediate initiation of all cases detected through GeneXpert and found to be Rifampicin resistant on Category IV regimens, hence the increase in initiation of patients under this category in 2013.

Also improving was the total of MDR-TB cases enrolled on treatment. Although there continues to be a gap between cases detected and those started on treatment, the gaps have significantly decreased with the implementation of GeneXpert and use of other molecular tests like line probe assay (LPA). Although the new guidelines allow for initiation of DR-TB suspects on Category IV regimens empirically, extra precautions are taken to avoid starting patients on treatment without proper diagnosis. Samples for culture and DST are expected to be taken from all empirical patients within the first month of treatment in order to reclassify them according to their resistant pattern once results are known. This explains the noted declines in empirical cases being started on treatment over the four quarters of 2012.

3 NATIONAL TB CONTROL PROGRAM (NTCP)

The National Tuberculosis Control Program (NTCP) is one of the country's 13 public health programs. The NTCP is charged with the responsibility of planning, implementation, monitoring and evaluation of TB control services in line with the global and regional strategies.

3.1 Organizational structure

The NTCP is structured at three levels namely the National, regional and facility levels; and operates under the Director of Health Services of the Ministry of Health, which is in turn under the responsibility of the Principal Secretary and the Honorable Minister. Technically, the NTCP Manager is assisted by a National IPC coordinator, a DOTS coordinator, Pediatric TB coordinator, TB/HIV coordinator, a Monitoring, Evaluation and Research Officer, Grants coordinator, two national MDR/XDR-TB coordinators and a Pharmacist. At regional level there are four regional coordinators and four regional IPC coordinators.

The TB regional coordinators are part of the Regional Health Management Teams (RHMT) of their respective regions where they supervise all TB/HIV activities at facility level as well as the DOTS Officers responsible for TB case registration and treatment in health facilities. The facilities in turn support the adherence officers and treatment supporters, while at community level the community DOT supporters report to the DOTS officers.

3.2 Health Facilities

Currently, there are 83 TB Basic Management Units (BMUs) consisting of regional government hospitals, health centers, mission hospitals, industry health services as well as private practitioners. Each of these BMUs has a focal person referred to as the TB nurse who carries out all TB/HIV related activities. Currently, 24 adherence officers are stationed in 21 BMUs and are equipped with a motorbike to facilitate the follow-up of patients who interrupt their treatment. They are also responsible for supervising treatment supporters who are the main thrust in the community based care model.

3.3 Drug Resistant Tuberculosis (DR-TB) Patient Management

The national TB hospital is responsible for providing specialized DR-TB management which has been decentralized to Mankayane Government Hospital, Piggs Peak Government Hospital, Matsapha Comprehensive Healthcare clinic, Hlathikhulu Government Hospital, Good Shepherd Hospital, as well as Matsanjeni and Nhlangano Health Centers.

At community level, various stakeholders including Community Healthcare Workers (CHWs), Civil Society Organizations (CSOs), Non-Governmental Organizations (NGOs), Community-Based Organizations (CBOs), Faith- Based Organizations (FBOs) and Traditional Healers in their varying capacities deliver TB care in close collaboration with the MDR-TB regional teams.

3.4 Program Mission Statement

The mission of the NTCP is to provide effective national leadership in the country's response to the TB epidemic in an effort to reduce TB-related morbidity and mortality as well as significantly mitigate the socio-economic impact of this curable and preventable disease on the population, thereby ensuring a healthy and productive Swazi nation.

Vision A Swaziland free from TB and its associated socio-economic consequences

3.5 Post-2015 Global TB Strategy

Swaziland has adopted the Post-2015 Global TB Strategy launched at the 67th World Health Assembly in May 2014.

The 2015-2019 NSP is based on this framework whose vision is a world free of tuberculosis - zero deaths, disease and suffering due to tuberculosis. Thus, the NSP objectives have been aligned to comprehensively embrace the Principles as well as the Pillars and Components of the Post-2015 Global TB Strategy:

Principles:

1. Government stewardship and accountability, with monitoring and evaluation

2. Strong coalition with civil society organizations and communities

3. Protection and promotion of human rights, ethics and equity

4. Adaptation of the strategy and targets at country level, with global collaboration

Pillars and Components:

1. Integrated, patient-centred care and prevention

i. Early diagnosis of TB including universal drug-susceptibility testing, and systematic screening of contacts and high-risk groups

ii. Treatment of all people with TB including drug resistant TB, and patient support

iii. Collaborative TB/HIV activities, and management of co-morbidities

iv. Preventive treatment of persons at high risk, and vaccination against TB

2. Bold policies and supportive systems

i. Political commitment with adequate resources for tuberculosis care and prevention

ii. Engagement of communities, civil society organizations, and public and private care providers

iii. Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control

iv. Social protection, poverty alleviation and actions on other determinants of tuberculosis

3. Intensified research and innovation

i. Discovery, development and rapid uptake of new tools, interventions and strategies

ii. Research to optimize implementation and impact, and promote innovations

3.6 TB/HIV Collaboration

The NTCP and Swaziland National AIDS Program (SNAP) have established a collaborative mechanism referred to as the National Coordination Committee (NCC) to guide the successful implementation of the WHO recommended framework for collaborative TB/HIV activities. With respect to the reduction of HIV burden in TB patients, an initiative led by the NTCP; HTC, CPT and ART provision to all TB patients has been scaled up over the last five years. Interventions aimed at reducing the TB burden among PLWHIV has commenced with the roll out of systematic intensified TB screening, Infection Prevention and Control (IPC) and the implementation of Isoniazid Preventative Therapy (IPT).

The NTCP NSP aims to strengthen the implementation of TB/HIV collaborative activities in line with the WHO-led external program review (April 2014) recommendations. To this end, the NTCP will closely collaborate with NGOs, CBOs, FBOs and other organizations that provide home-based care services, which will in turn contribute to expanding community-based TB care.

Central Medical Stores (CMS) To ensure an uninterrupted supply of quality-assured first and second line anti-TB drugs, the NTCP has established a collaboration with the Global TB Drugs Facility (GDF).

In order to ensure an effective supply chain management system, the NTCP collaborates actively with Central Medical stores (CMS) via a dedicated NTCP pharmacist. Technical partners also play a pivotal role in capacity building within the NTCP by building electronic systems to ensure proper quantification, ordering and uninterrupted supply of anti- TB drugs.

National TB Reference Laboratory (NTRL) Effective laboratory services are critical to a successful TB control program. The national TB laboratory network consists of 25 peripheral laboratories under the leadership of the National TB Reference Laboratory (NTRL). The NTRL has collaborated with the Supra National Reference Laboratory (SNRL) in Uganda to upgrade the country's BSL 3 reference laboratory to facilitate the provision of 2nd line DST services in Swaziland.

The NTRL has developed the infra-structure and capacity for rapid molecular diagnostic testing with GeneXpert MTB/RIF as well as mycobacterial culture and 1st line DST (LPA, MGIT, solid culture). The implementation of GeneXpert MTB/RIF at all microscopy centers will impact on the turnaround time for feedback of results to health facilities and improve the initial loss to follow-up of TB patients by facilitating the prompt initiation of appropriate TB treatment. The NTRL is also responsible for maintaining national laboratory quality control as well as capacity building, mentoring and supervision.

NTCP Partners The NTCP collaborates with technical and financial partners within and outside the country. The technical partners include the World Health Organization (WHO), the University Research Corporation (URC), Medicin sans Frontiers (MSF) and the Clinton Health Access Initiative (CHAI). The NTCP has numerous implementation partners who recently formed an umbrella body referred to as the Swaziland Stop TB Partnership. The members of the Swaziland Stop TB partnership include Good Shepherd Hospital, Cabrini Ministries.

NTCP funding The NTCP is funded mostly by the Swaziland Government with additional funds from the Global Fund (GFATM), TB REACH and the World Bank. The programme has an established budget line that covers some human resources, first and second line anti-TB drugs and administrative costs. The WHO and PEPFAR also provide resources for closing funding gaps in the implementation of programme activities.

Table 1: Major Technical and Financial Partners of NTCP

Partner Area of Work

WHO Technical and Financial

URC Technical and Financial

MSF Implementation, Technical and Financial

MSH Technical and Financial

FIND Technical and Financial

IHM Technical

TB REACH Financial

CHAI Technical and Financial

3.7 Government commitment and partnerships

Over the years there has been an increasing government commitment in TB control activities in line with Global initiatives.TB is among the national top 3 priority diseases and was declared a national emergency in 2011.

Government commitments include:

i. Financial allocation for the NTCP and TB hospital (US$ 4 million equivalent to E40 million annually)

ii. Generally uninterrupted government fully funded supply of anti-TB medicines, ARVs and laboratory reagents and commodities.

iii. Special waiver for TB medicines to be procured by direct procurement for 1 year supply and 1 year buffer to ensure undisrupted supply of anti TB medical supplies.

iv. Existence of the National Health Sector Strategic Plan (NHSSP 2008-2013), the NTCP strategic plan and technical guidelines for programme support and implementation.

v. The distribution and coverage of health care facilities is within 8 km of the population enabling easy geographical access to TB/HIV diagnosis, refill and continuum of care.

vi. Government initiated successful mobilization of additional resources from donor and collaborating partners.

4. DEVELOPMENT OF THE 2015 – 2019 TB NSP

The development of the 2015-2019 NSP was initiated in November 2013 at the annual workshop on National Strategic planning for Tuberculosis Control in Cepina, Italy. The process of development is further detailed below.

4.1 Process of NSP working group

A core NSP development team was formed and divided into six thematic areas: Diagnostics and DOTS, TB/HIV and Infection prevention & Control, MDR-TB and Pediatric TB, Drug supply, Monitoring & Evaluation, and Programme management.

4.2 Situational Analysis

Table : SWOT and PESTEL Analysis

4.3 Recommendations from the NTCP external program review of 2010 – 2014 NSP The NTCP has been implementing a National TB Strategic Plan 2010 – 2014 which closes out at the end of 2014.

Therefore, to inform the development of a successor plan, the government through the MOH requested WHO to lead a joint external review of the implementation of the plan and to assess its impacts on TB control in the country. The review was designed to identify successes and best practices to be enhanced and built upon, opportunities to be optimized, gaps to be embraced, and challenges to be addressed. The report from the review has not only informed the development of this plan, but also served as a guide for government investment and resource mobilization for TB control.

Highlighted below, are some of the most critical recommendations from the review:

4.3.1 Program Coordination – the NTCP should undertake to:

i. Sustain adequate Government funding allocation for TB Control.

ii. Establish incremental government funding for core TB Control activities over and above medicines, including securing Government funded coordinators posts at national and regional level.

Strengths Availability of Drugs and Medicines, Adoption and scal up on new diagnostic technologies, Establishment of LMIS, CMIS and LISGIS mapping, and Geo Tagging of patients, Public health bill in process, Existence of technical and financial partners, Existence of Public Private Partners (PPP), stop TB PARTNERSHIP, Wide DOTS coverage, TB/HIV services, Existence of policy documents, Referral Hopitals for DR -TB patients.

Weaknesses Limited skills in research, Lack of integrated TB training manual, Unavailability of Training Database, Lack of ACSM strategy, Limited TB integrated community services, Inadequate Paediatric TB management services, Insufficient audiometry services for baseline assessment for DR-TB patients, Poor adherence to guidelines in implementing TB services, Weak Psychosocial Support systems.

Opportunities Political commitment, Ministry of health embraced PPP, Elderly grants, Good communication coverage (telecommunication, internet access), Introduction of LMIS, LIS and CMIS, Existence of National TB/HIV Coordinating Committee (NCC), Community involvement and participation in TB activities, SADC declaration on addressing TB in the mining sector, Regional Harmonized Framework on TB in the mining sector.

Threats Small budget for health (<15%), High Stigma for TB, High youth unemployment, Elderly being care-gives, Drug abuse on the increase, Staff rotation, lack sustainability of donor-funded activities and HR, High HIV prevalence, Unavailability of 2nd line paediatric formulations, Inadequate infrastructure for TB control inadequate ventilation and exposure to occupational hazards, e.g. factories, supermarkets, mines, etc. Poor IPC measures in congregate settings

Political factors Declaration of TB as emergency, Prioritization of the health sector, Procurement of Drugs 1st line drugs, Inter-ministerial collaboration (Good relationship with parliament, ministry of finance, ministry of public service), Public health bill being developed, Health Sector policy and strategic documents reflect TB well, Ministry of health embraced PPP, collaboration with partners, Tax Exemption of medical supplies

Economic factors Low middle income, recovering from economic crisis, growing industrial activities lack proper industrial health measures and migrant workers, reliance on SACU revenue, About 70% of people living below poverty line, Public debt not an issue, government provides 50% of employment

Social factors Strong influence of traditional leaders and healers, Stigma for TB, High youth unemployment rate, Elderly being care-givers, High number of Orphaned and Vulnerable Children population (1 in 3 children is OVC), Elderly grants, Drug and alcohol abuse on the increase, Gender dynamics for both sexes, affecting health seeking behaviours, Violation of the right to treatment ( women)

Environmental factors Seasonal weather changes, difficult terrain, Poor housing conditions in peri-urban and rural communities (ventilation and overcrowding), hazardous working environment (inadequate ventilation and exposure to occupational hazards), e.g. factories, supermarkets, mines, etc.) Health facility infrastructure (inadequate ventilation and exposure to occupational hazards)

Technologic factors Relatively good communication coverage, Government initiative on electronic Patient, management Information System, Adopting new diagnostic technologies, Establishment of LMIS and LIS, GIS mapping and Geo Tagging of patients, Inadequate computer hardware; IT skills for Electronic system management in all health facilities; limited network coverage

Legal Public health bill in process but does not include issues of Drug resistant TB (e.g. MDR and XSR- TB), Age of consent for HIV testing is 12 years, No legal provision for occupational compensation for workers with respect to TB, Availability of health policy

iii. Collaborate with RHMTs at all levels to exercise full stewardship for programme strategic directions through increased ownership and oversight through the “Three Ones Principle” (one national plan, one national coordinating authority and one M&E framework) in order to create complementarity and synergy, rather than competition, with and between collaborating NGO partners.

iv. Strengthen collaboration between NTCP and SNAP in TB/HIV activities.

v. Spearhead documentation and scale up of best practices arising from own and collaborating partner initiatives.

vi. Strengthen and promote supportive supervision at all levels.

4.3.2 Programmatic Management of DR-TB – the NTCP should ensure:

i. Regular knowledge and skills development for all cadres of health care workers in all DR-TB facilities.

ii. All DR-TB initiating sites incorporate on-site basic audiometry services.

iii. FLD DST is conducted for all GeneXpert MTB/RIF diagnosed cases; and SLD DST for all confirmed MDR-TB cases and suspected MDR-TB treatment failures

iv. Collaboration with the TB hospital management to:

- Mobilize resources to procure diagnostic ABR machine for the Audiometry Unit to facilitate accurate diagnosis of hearing loss type

- Establish a government funded post for an Audiologist

- Ensure availability of reliable patient transport (Ambulance)

- Create isolation wards for MDR-TB suspects and confirmed cases at hospitals and clinics

- Promote and support operational research on the diagnosis and management of MDR-TB

- Plan for and conduct a repeat DRS

- Provide at least one additional nurse and a social worker to the community Care team

- Establish independent community care teams at all satellite treatment centers.

- Provide regulatory guidance on the giving of injections for community treated patients

4.3.3 TB Laboratory Services – the NTRL should:

i. Review reporting lines between Laboratory services and NTCP given that the NTRL is TB specific service

ii. Take responsibility of the entire TB lab network in country

iii. Secure numbers and security of tenure of staff

iv. Improve blinded rechecking for Microscopy, slide boxes, data analysis, feedback reports, and corrective action.

v. Liaise with the NTCP to promote the use of 'Spot' samples to improve TAT

vi. Collaborate with the NTCP to review the TB diagnostic algorithm and incorporate GeneXpert testing for re-treatment cases

vii. Calibrate all machines that are due and establish a maintenance plan for all GeneXpert machines in the country

viii. Finalise the GeneXpert MTB/RIF roll-out implementation and sustainability plan

ix. Evaluate the extent of concordance of phenotypic and genotypic Rif DST

x. Develop/Finalize the following Key guidance documents:

- Finalise TB lab strategic plan

- Microscopy and EQA manual

- Sample referral guide

- MDR & XDR notification and surveillance system

xi. Expedite the development of local capacity for Second line DST

4.3.4 Medicines and commodities procurement and supply chain management (PSM)

i. The Ministry of Health:

- Should expedite process to enact the new Pharmacy and Medicines Control Bills that provide for a Pharmacy Council and a Medicines Regulatory Authority.

- Increase the storage capacity at CMS

- Recruit needed additional human resources for the CMS system and secure their retention/absorption

ii. Ministry of Finance to ensure availability of foreign currency to facilitate easy international transactions for medicines

iii. NTCP to actively involve CMS in the quantification and procurement of anti-TB medicines and supplies;

iv. NTCP and CMS to integrate the manual LMIS for anti-TB medicines into the electronic MMIS for other medicines

v. CMS to :

·Extend the Pharmacovigilance system beyond ARVs ·Mobilize support for the establishment of a Quality Control Laboratory in the country.

4.3.5 Basic DOTs (Diagnosis, Treatment and Partnerships) – NTCP should:

i. Increase access to diagnostic (GeneXpert MTB/RIF and microscopy) services

ii. Scale-up the use of molecular tests for rapid diagnosis of MDR-TB

iii. Ensure access to x-ray facilities

iv. Train HCW at all levels on TB diagnosis and management

v. Strengthen treatment monitoring, treatment adherence support and effective management of patients lost to follow-up

vi. Establish cross border collaboration with neighbouring countries for TB management

vii. Conduct quarterly supervisory visits to peripheral level facilities

viii. Conduct periodic data quality audits

ix. Collaborate closely with CMS to ensure uninterrupted supply of TB medicines

x. Strengthen training, supervision and mentoring of facility health workers

xi. Consider the establishment of out-reach programs for hard to reach areas

xii. Integrate TB into community outreach programs

xiii. Train Regional M&E officers and TB coordinators on quality improvement

xiv. Consider provision of psycho-social support for TB patients

4.3.6 Public-Private and Public-Public Partnerships for TB control should:

i. Document and replicate PPP innovative experiences where feasible

ii. Develop a contingency exit strategy

iii. Re-asset effective Government stewardship of national health sector response through enforcing a “Three

Ones” approach

iv. Develop guidelines for PPM-DOTs

4.3.7 TB/HIV and Infection Control

i. RHMTs should ensure standardization of the TB/HIV package of care for all partners and collation of data in all facilities

ii. NTCP & SNAP should conduct joint TB/HIV trainings for health care workers

iii. SNAP should revise HIV recording and reporting tools to capture IPT columns

iv. SNAP should enforce adequate screening and monitoring for TB among all HIV patients (Pre-ART and ART)

v. Strengthen TB screening in OPD and among patients with comorbidities e.g. NCDs

vi. Improve infrastructure to upgrade PMTCT sites to TB treatment initiation sites

vii. Revise HIV and ANC registers to track TB diagnostic results

4.3.8 Monitoring and Evaluation – the NTCP should:

i. Review and update M&E system in line with WHO new (2013) TB case definitions

ii. Collaborate on HMIS development to ensure capture of minimum TB indicators

iii. Conduct both a TB prevalence and Drug-Resistance Survey

iv. Determine the level of under reporting through Inventory studies especially Childhood TB

v. Liaise with government to develop and implement a Vital Registration system to better measure TB-related mortality

5 GOALS, OBJECTIVES AND STRATEGIC INTERVENTIONS

The NSP objectives embrace all the various components of the Post-2015 Global TB Strategy in the following manner:

1. Integrated, Patient-centered Care and Prevention

a) Early diagnosis of tuberculosis including universal drug-susceptibility testing, and systematic screening of contacts and high-risk groups.

b) Treatment of all people with tuberculosis including drug-resistant tuberculosis, and patient support.

c) Collaborative TB/HIV activities and management of co-morbidities.

d) Preventive treatment of persons at high risk, and vaccination against tuberculosis.

2. Bold Policies and Supportive Systems

a) Political commitment with adequate resources for tuberculosis care and prevention.

b) Engagement of communities, civil society organizations, and public and private care providers.

c) Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control.

d) Social protection, poverty alleviation and actions on other determinants of tuberculosis.

2. Research and Innovation

a) Discovery, development and rapid uptake of new tools, interventions and strategies.

b) Research to optimize implementation and impact, and promote innovations.

5.1 Objective 1: To increase TB case detection rate from 46% in 2013 to 70% in 2017% and 80% in 2019.

Rationale Swaziland has been experiencing a continuous decline in the number of new TB cases notified annually since 2010. A total of 11,057 new TB cases were notified in 2010, whereas 6,665 new TB cases were notified in 2013 (NTCP Annual Report, 2013) depicting a 39% decline in case finding. The WHO estimates that Swaziland should have notified an average of 13,870 new TB cases in 2012 (WHO Report, 2013).

Sub-analysis of TB notification trends indicate a sharp decline in the number of notified smear negative TB cases from 5,064 in 2010 to 3,111 in 2012 while notifications of smear-positive and extra-pulmonary TB were on a steady increase (NTCP Annual Report, 2012). According to the ISTC (2014), all providers who investigate and treat TB patients must recognize that, not only are they delivering care to an individual, they are assuming an important public health role that entails a high level of responsibility to the community and to the individual patient.

In 2012 Swaziland adopted the GeneXpert MTB/RIF technology, a highly sensitive first-line diagnostic test scientifically proven to be ~20% more sensitive than smear microscopy, this has significantly improved the diagnosis of smear-negative TB cases that would have been undiagnosed in the pre-GeneXpert era. Given this increase in smear-negative TB diagnosis, the NTCP projects:

- Current case notification rate will be sustained despite the noted declining trend

- A compounded 1.5% average annual increase in the TB case notification rate over the next 5 years.

The national TB guidelines are modelled on international standards of care, therefore diagnosed TB cases will be promptly initiated on appropriate TB treatment (IST, 2014). Linkage-to-care of diagnosed patients aimed at reducing systemic leakages of diagnosed TB patients is a primary focus of this National Strategic Plan.

Childhood TB has, until recently, been largely ignored globally and the NTCP recognizes the need to address and…