Gap Analysis: Tuberculosis Care in Malawi Round 11 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria Africa 3: Team Malawi Arianna, Babatunde, Jeannie, Neway, Semret and Thurston

- Population = 13.1 Million -50% is under 15 years of age -Population growth 2.763% -15% is Urban -39% lives below poverty

"We came back to wait for the result, we waited and waited but the result never comes out. We went to the health center to find out about the result only to be told that the sputum was sent to Ntcheu District hospital, if the result came we will inform you. We waited and waited then we went again for a second time, third time only to be told we shall be called. We stayed at home.....” Simwaka BN et.al. International Journal for Equity in Health 2007, 6:24 We need to listen to the community …

Summary of Malawi health Services 46% reside with in 5km of health facility 97% ANC attendance only 54% deliver with an assistance of skilled worker. – 38% = institutionalized delivery 72% of Tb patients are HIV positive MDR TB on the rise.

23,929 (2008) [1] TB case notifications 21,000 (2008) [1] TB incidence (smear positive) number 140/100,000 (‘08) [1] TB incidence (smear positive) rate 37,000 (2009) [2] TB prevalence, all forms (number) 243/100,000 (‘09) [2] TB prevalence, all forms (rate) 87% (2008) [2] TB treatment success rate (%) 22 (2009) [2] TB mortality, all forms excl HIV (per 100,000) 158 (2004) [3] DALYs (‘000), Tuberculosis 1.WHO. Global Tuberculosis Control: a short update to the 2009 report 2.WHO Global Tuberculosis Control Report WHO (

920,000 (2009) [1] People living with HIV 440,000 (2009) [2] Estimated number of people needing ARV under 2010 WHO guidelines 240,000 (mid-2011) [3] People currently on ART 11% [1] Adult HIV-prevalence (%) 1.UNAIDS report on the gloabl AIDS epidemic WHO. Towards Universal Access Progress Report Global Fund-supported programs, mid 2011-results

Pathway to TB diagnosis – Malawi. Int. J Equity Health. 2007; 6: 24.

GAPS “ In 2004, of the 12,943 TB cases (4 urban district) accounted for 47% of all TB cases in Malawi. 50% of these cases were smear positive, justifying  increase TB case detection rate Decreasing TB case notification 29,000 cases in 2005 VS 26,000 in 2009 Malawi - Health Sector Strategic Plan High costs of seeking TB care – 126% - 240% of monthly income. Only 48% of TB cases are detected in Malawi, meaning that a startling 52% of people with TB are 'missing' from TB services and hence TB notification rates. WHO: Global tuberculosis control: Surveillance, planning and financing. Geneva, 2005.

GAPS Poor case finding and loss to follow up Diagnosis for TB in rural districts is still centralized Delays in transportation of specimens & getting results Laboratory services - lack adequate HR & funding Poor capacity of the national reference laboratory Poor coordination of public-private activities in the health sector Poor adherence to procurement systems No report on PLWHA on isoniazide prophylaxis

Steps to TB diagnosis – Malawi - Int J Equity Health. 2007; 6: 24. Repeated visits Opportunity costs Transport costs leading to delay and lost cases

Proposed approaches to increase case finding 1. Intensified Active TB case finding using WHO approved TB symptoms screening questionnaire - in high risk groups -All patients in healthcare facilities, ANC clinics, HIV care clinics – all steps ! – Pregnant women and young children – Contacts of TB cases, migrants, prisoners, the urban poor – Alcohol users, drug users, displaced people, smokers and, diabetics 2. Decentralize TB diagnosis ( microscopy) both at public and private -Strengthen lab facilities / referral laboratory – central lab to -Train health care workers and Health Surveillance Agents -Improve the quality of lab networks, -Set up community sputum collection points and facilitate transportation 3. Community mobilization 4.Supply chain management 5.MDR TB – laboratory, screening and 2 nd line treatment

Indicators Ensure 100% follow up with all sputum positive patients and their families and close contacts via paid community health volunteers Strengthen health systems supply chains to health centers Number of PLHIV put on IPT Provide microscopes and necessary diagnostics equipment to every facility where there is a trained HAS (around 200) Number of TB cases identified 100 HSAs to be trained on microscopy each year over 5 years

THANK YOU

Steps in the TB Case Detection Process Patient travels to clinic Clinic has staff and tools necessary to conduct TB tests Health Center provides results to patient TB Tests are Accurate Patients have ability to provide 3 days worth of sputum samples Health Center follows up with patients who test positive as well as with their family members Sputum positive patients referred for DOTS treatment DOTS treatment readily available and adhered to through private and public partnerships

Global Fund in Malawi ($390 mil. HIV/AIDS, $120 mil. Malaria, $11 mil. TB, $52 mil. HSS) 7 grants funded = 2 malaria, 3 HIV/AIDS, 1 TB, 1 other. - National Response to HIV/AIDS [R1] - Scaling up Prevention and Treatment of Malaria [R2] - Orphan Care and Support (HIV/AIDS) [R5] - Health Systems Strengthening (HIV/AIDS, TB, & Malaria) [R5] - Accelerating Implementation of Anti-malaria Treatment (ACTs) and Access to Nets [R7] - Towards Sustainable and Equitable TB control [R7] - HIV/AIDS Behavioral Change Communication and Scaling Up of HIV Prevention Services for Young People [R7] - Scaling Up Malaria Interventions to Achieve Universal Coverage [R9]

GF spending in Malawi on TB Board approved: $9,120,816 Total grant amount: $9,120,816 Total amount disbursed: $2,825,106