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

2. 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

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

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

5. Tuberculosis Case Detection

6. 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.

7. 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%.

8. 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

9. 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

10. End

11. Random Slides

12. Case Finding Gaps

13. 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*

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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 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

23. 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

24. Thanks!

25. 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