Country Progress Report (Papua New Guinea) The ninth Technical Advisory Group and National TB Programme Managers meeting for TB control in the Western Pacific Region Manila, Philippines December 2014

TB Epidemiology

TB epidemiology

TB Epidemiology High transmission of TB in communities as a high proportion of SS+ patients are among the young economically productive age group years old, mainly among females; High transmission of TB within households: 28% of TB cases are children, 2013; TB in urban areas: 70% of cases during last 5 years ( settlements, overcrowding, culture of “extended families”) TB in mainly in Southern region: NCD is the most important “TB hotspot”; reports 5 x national average notification, 25% caseload, only 5 % population TB/HIV: half of provinces have high TB/HIV burden Estimated MDR TB rate, New 4.5% -Retreatment 24%

Major successes Steady increase of case notifications Procurement of all medicines from GDF, no stock outs TB patients receiving HIV tests have increased from 13% in 2011 to 24% in DRS is going to finalise by the end of 2014.

Major Successes, NSP TB CN, , was approved by GF, 21 Million USD 3.External review of TB program, Feb TB CN for NCD, 10 million AusD, DFAT 5.M/XDR TB Emergency Response Team since August Inter-ministerial Task Force since Nov Campaign by PM, Oct and Nov, 2014

Major challenges Health System related factors: Lack of manpower at all levels, HR crisis (quantity) Poor managerial capacities at all levels  Poorly supervised staff resulting in low staff morale (unprofessional behavior, low motivation, and absenteeism) “You can have the best strategy and the best building in the world, but if you don’t have hearts and minds of the people who work with you, none of it comes to life”. Renee West  Poor capacities in strategic planning, budgeting and monitoring, and program evaluation Poor maintenance of infrastructure ( run down facilities with obsolete equipment) Limited ownership at provincial, district, health facility, and community levels Poor coordination and communication between different levels of government because of fragmentation of organizational and administrative health structures

Major challenges TB program specific factors: – TB patients present late for diagnosis resulting to on-going transmission in the community – Clinicians over reliance on x rays and clinical assessment of TB and lack of labs resulting in low bacteriological confirmation of TB ( high rate of sputum not done) – Limited supervised treatment, most patients self administer – High defaults with limited retrieval actions – Limited supervision and constructive feedback at all levels – High child TB, BCG uptake low <60%; BCG stock-outs – Slow uptake of TB/HIV collaborative activities in most provinces – Weak involvement of provincial offices in the implementation of drug resistant TB, poor monitoring and supervision of DR TB, infrastructure inadequate for DR TB management/ infection control issues

National TB Strategy/Policies Timeframe: , aligned with WHO End TB strategy and National Health Sector Plan NSP prioritized 30 BMUs ( 10% of BMUs) in 14 provinces – 75% defaulters ( all cases) – 65% smear not done – 53% of national TB burden GF support needed for 28 BMUs (12 provinces) – Two BMUs to be supported by DFAT and MSF

National TB Strategy ( targets and budget)

Reach the unreached Intensive case finding: among child contacts of bact pos. patients and PLWH Contact investigation: not working fully, info not available. TB-HIV: In practice is happening, but data not collected by HIV program. Child-TB: serious issue; special intervention in GF CN

Laboratory LED microscopes: No roll out Xpert; 17 in country (National 1, Regional 4, Provincial 12 and District 0 (See map) Quality Assurance – Participation: per quarter between 19.5% and 35.6% of microscopy sites – s Laboratory Information Management System – Manual entry TA partners; – WHO, QMRL, DFAT and World Vision

GeneXpert Locations in PNG Current Proposed Partners/PHO/Private

Surveillance Quality of TB reports – Provincial teams (informally designated – TB TB/Leprosy Officer, M and E officer and Health Information officer) were trained on data quality assessment that includes availability, completeness, consistency, accuracy and timeliness New Case Definition roll out – Forms for drug sensitive TB will be revised to align with the WHO new case definitions – MDRTB Guidelines revision initial meeting was conducted in October. This is still on-going.

Surveillance Data Analysis and utilization – National Level: Quarterly reports are circulated by NTP Manager; also used to identify and prioritize facilities to focus on. – Provincial Level: some provinces analyse their data for management meetings and provincial reviews.

PMDT Treatment success rate: 14%, 2011 Special case: Daru ( dilapidated hospital, high transmission of DR-TB in the community (half of MDR TB cases are new) and hospital (4% staff sick with M/XDR TB), no doctors, high level of outrage) Barriers: HS barriers ( no HCWs ), lack of PC3 lab, high costs of culture and DST, high initial LTFU rate Action plans:  Completion of DRS  M/XDR TB emergency Response team  DFAT NCD project  Implementation of PMDT activities in TB NSP ( partially financially supported by GF)  Continuous advocacy

MDR/XDR-TB Emergency Response Established in August 2014 Five (5) meetings conducted One meeting conducted by Health Minister & governors of Western, Gulf & NCD to gain political interest. Budget needed: PGK8M (K2M for Prime Ministers Media Campaign & K6 to Gulf, NCD & Western) Partners’ presence Highlights of provincial responses: – Action plans submitted – Intensive LTFU tracing ( decreased from 36% to 14%, NCD) – Argument manpower support Treatment supporters Additional hospital staff

Bold policies and supportive systems In 2014, the GoPNG began to implement its major health financing reform which provides universal coverage through its “Free Primary Health Care and Subsidised Specialist Services Policy.” Health facilities will no longer charge user fees as they used to whenever operating funds could not support their service delivery levels. The policy was put into effect on the 24th of February 2014 and is targeted at poverty reduction and addressing the inequities in health care access.

Drug Regulation - Progress since the last meeting Medicines and Cosmetic Act 1999 and Regulation 2001 is under review and the first national consultation workshop was held in Sep 2014 Provincial Pharmaceutical Inspectors Training held in Sep 2014 National Strategic Plan on Strengthening Medicines Regulatory Framework was developed in Nov 2014 QC testing of TB drugs at TGA Australia Global Fund Concept Note for HSS has been endorsed in Nov The grant will be used to strengthen product registration, setting up a QC lab, compliance and inspection 2-week training on Logistics Management Information System in Nov 2014

Patient centred care: involvement of patients and civil society Community mobilization activities: development of CBOs based on NSP Involvement of patient groups in TB control : were involved in NSP and CN development, members of of TB WG Forms of social support to TB patients: transportation costs and food are included in TB GF CN and NCD DFAT project