Global Fund Grant Proposal Round 11: Tuberculosis Nathan Furukawa Gabriela Boyle Rebekah Miner Paa Kobina Forson Xiaoxue Huang Hunter Pugh

Tuberculosis Burden 22 High Burden TB countries account for 80% of the world's TB cases- Cambodia is one of those high burden countries as identified by the WHO. Cambodia leads the region in incidence, prevalence, and deaths due to TB 1993 Reestablishment of the national DOTS program History of GF grants Round 2, 2004: Tuberculosis Grant: Decentralization Round 5, 2006: Tuberculosis Grant: Scaling up Rural TB & TB/HIV Services Round 7, 2009: Tuberculosis Grant: MDRTB, TB/HIV, and Lab Services

Tuberculosis Incidence Incidence: 62,000 new cases 437 per 100,000 population

Tuberculosis Deaths TB Deaths: 8,600 deaths 61 per 100,000 population

Tuberculosis Case Detection

Provincial Map 100% DOTS Coverage Rate DOTS availability (2007): 41 health operational districts (of 77 total) 461 Health Centers (of 966 total) 80% of the population is rural 21% of poorest 1/5 of the population travel 5km+ to reach a health center.

Strength: Treatment Success Unknown Threat: MDR-TB Treatment, MDR-TB, and HIV Strength: Treatment Success Unknown Threat: MDR-TB The HIV/TB Disconnect Reach of HIV services does not extend as far as the decentralized DOTS program The main barrier relates to limited access to culture for diagnosing sputum smear-negative disease 70-100% of all newly diagnosed HIV-infected persons screened for TB, but only 14-83% of TB patients were tested for HIV. The rate of active disease found upon screening ranged from 9% to 26%.

Inputs and Activities Promoting Decentralization -Expansion of basic services rurally by expanding DOTS to all health centers -Operational research funding (Nate) Improving Case detection (Xiao) -Implement active case finding -Private sector engagement -Mobile microscopy service pilot Diagnostics (Nate) -Expand access to diagnostics rurally -Establish Universal DST access means Healthcare Worker Training (Becca) -2.3 doctors and 7.9 nurses per 10,000 -Training low skilled health workers DOTS Structural Support -Funding security -Streamlining coordination within decentralized system Drugs Procurement (Paa) -59,784 people require treatment -Secure 1st line drug supply chains -Stockpile 2nd line drugs HIV/TB Service Expansion (case det.) -Coordination of TB and HIV scale up by health center catchment Vulnerable Populations (part of case det) -Targeting of impoverished, slum areas, and ethnic minorities

Some Outputs Promoting Decentralization DOTS Structural Support -Improved access to DOTS rurally Improving Case detection -Achieve case detection above 75% -Increase % completing treatment Diagnostics -Characterize MDR-TB burden -Streamline diagnosis and treatment Healthcare Worker Training -Task shifting without internal brain drain DOTS Structural Support -Coordinated data collection -Sustainability Drugs Procurement -Avoid stockouts -Access to MDR/XDR-TB Treatment HIV/TB Service Expansion -Integration of services -Improved health metric outcomes Vulnerable Populations -Reducing TB clusters and health disparities

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Case Finding Gaps

Tuberculosis Tuberculosis Treatment, Care and Support   Treatment, Care and Support # of treatment units implementing DOTS # of estimated new smear-positive TB cases detected under DOTS # of smear-positive TB cases registered under DOTS successfully treated* # of persons completing DOTS+ treatment for MDR-TB*

What the program does with the inputs to fulfill its mission IMPACT Resources dedicated to or consumed by the program What the program does with the inputs to fulfill its mission Direct products of program activities Political commitment Allocates the highest percentage of government’s budget on health (16%). Still insufficient: 2002 was $2.7 per capita and about $5.8 in 2009. Below minimal care package of $12 per person Goal attainment

Brief History 1863 - Cambodia becomes a protectorate of France. French colonial rule lasts for 90 years. 1953 - Cambodia wins its independence from France. 1975 - Khmer Rouge led by Pol Pot occupy Phnom Penh. Year Zero starts. The total death toll during the next three years is estimated to be at least 1.7 million. 1979 The Vietnamese take Phnom Penh. Pol Pot and Khmer Rouge forces flee to the border region with Thailand. 1993 The MoH reestablishes its long nascent national TB program

Global Fund Grant Proposal Round 11: Tuberculosis Nathan Furukawa Gabriela Boyle Rebekah Miner Paa Kobina Forson Xiaoxue Huang Hunter Pugh

Sources of Loss in TB Gap Analysis GF Goals Potential Case Health Seeking Public Health System Diagnosis DOTS Treatment Sources of Loss in TB GF Goals 1.)  Case Detection to 80% 2.) Maintain Treatment Success Rate 3.)  Mortality Rate High Risk, Barriers to care Diagnostics DOTS Workers Health Staff Drug Supplies Private Sector Tracking Gap Analysis 92% treatment success 65% Case Detection

Cambodia Tuberculosis Funding Major Impact Categories 1. Improve Case Finding 2. Decentralization 3. System Strengthening Total 5 Year Budget: $81,535,403 Year 1 Budget: $24,311,481

Public-Private Management Increase Case Detection Active Case Finding Public-Private Management Community Contact Tracing Case finding Campaigns 40 sites TB screening at 55 ART sites HIV screening at all TB centers Costs: $30,000/ Screening Van x 30 S160/ case found in campaigns $400/ TB case diagnosed at HIV clinics Expand PPM in 2 more districts Train private providers & pharmacists on Nat’l Guidelines DOTS in select private clinics Referral database Details: $800/ mo. National PPM Director $500/ mo./ PPM NGO staff

Decentralization C-DOTS 228 Microscopy centers 5 Culture labs upgrades Diagnostics C-DOTS 228 Microscopy centers 5 Culture labs upgrades Digital X-Ray Pilot Diagnostic Staff Details: $130/ microscope x 1000 $1500/staff/yr. x 456 $40,000/ x-ray machine x 10 DOTS provision at 1051 HCs Support of 6000+ treatment cases Trainings of 9,800 DOTS watchers Community Advocacy activities Details: DOTS trainings in all 77 ODs $130/ case covered by DOTS $32/ case related to M & E activity Monthly supervisory visits to DOTS sites

TB System Strengthening Drugs Health Staffing Health Info System HIS Training HIS staff Compliance with Nat’l Reporting guidelines Details: 1000 staff trainings/yr 4000 refreshers/yr 200,000 1st Line 90,000 2nd Line 100,000 BCG vaccine 30,000 Vitamin B Details: $5/ 1st-line treatment $50/ 2nd line treatment 0.10/ Vit. B dose $2/ BCG Vaccine Public Salary Top Up Rural Staff Incentive Details: $4800/yr/doctor x 77 ODs $2400/yr/nurse x1051 HCs $50/yr./rural staff stipend

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Objective Emphasis Improve Case Detection Active Case Finding Private-Public Mix Decentralization Improve diagnostic capacity Expand C-DOTS TB System Strengthening Drug Supplies Adequate Staffing Levels Health Info System