GLOBAL FUND TB GRANT - INFORMATION SUMMARY, June 2023 I. BACKGROUND OF THE GLOBAL FUND In 2000, world leaders noted that AIDS, TB and malaria appeared to be unstoppable. In many countries, AIDS devastated an entire generation, leaving countless orphans and shattered communities. Malaria killed young children and pregnant women unable to protect themselves from mosquitoes or access lifesaving medicine. TB unfairly afflicted people living in poverty, as it had for millennia. The idea of global response to the 3 pandemics, arose through advocacy to world leaders. This was discussed at a G8 summit in Okinawa, Japan, in 2000. The real commitment began at the African Union summit in April 2001, continued at the United Nations General Assembly Special Session in June of that year, and was finally endorsed by the G8 at the summit in Genoa, Italy, in July 2001. A Transitional Working Group was established to determine the principles and working modalities of the new organization, and the Global Fund came into being in January 2002. As a partnership of governments, civil society, technical agencies, the private sector and people affected by the diseases, the Global Fund pools the world’s resources to invest strategically in programs to end AIDS, TB and malaria as public health threats. Since the creation of the Global Fund, more than US$55.4 billion has been disbursed in the fight against HIV, TB and malaria and for programs to strengthen systems for health across more than 155 countries, including regional grants, making the Global Fund one of the largest funders of global health. The Global Fund to Fight AIDS, Tuberculosis and Malaria is an innovative financing mechanism that seeks to rapidly raise and disburse funding for programs that reduce the impact of HIV/AIDS, tuberculosis and malaria in low- and middle-income countries. The Global Fund offices are in Geneva - Switzerland and has no presence in other countries, but is represented by the Local Fund Agent (LFA) at country level. The LFA monitors the grants, verifies reports and conducts capacity assessment of Principal Recipients; and may carry out other assignments on behalf of the Global Fund. At country level, the Country Coordinating Mechanism (CCM) is national committee that submit funding applications to the Global Fund and oversee grants on behalf of the country. Other responsibilities of the CCM includes, coordination of the development of the national request for funding, nomination of the Principal Recipient, oversight on Oversees the implementation of grants, approval of reprogramming requests, and ensures linkages and consistency between Global Fund grants and other national health and development programs.
Due to the context issues, Somalia is a non CCM country and the Global Fund Steering Committee (GFSC) carries out the roles of the CCM. Disease Data: 1 Drug sensitive TB - Annual New TB cases 43,000 2 Drug resistant TB - Annual New TB cases 2,100 3 Annual Detection 18,000 (2022) 4 Treatment Success Rate >90% 5 TB service points / 100,000 population 158 II. OVERVIEW OF SOMALIA GLOBAL FUND TB PROGRAM Somalia Global Fund Tuberculosis programme started in 2004 but actual implementation started in 2005. World Vision Somalia was elected to principal recipient replacing WHO which was earlier nominated to be principal recipient. Since 2005, World Vision has worked with Ministry of Health and other implementing organisations in provision of TB services across Somalia and Somaliland. Starting with Round 3 (2004-2008) of 5-year duration, the program laid down the infrastructure to deliver services. This was followed by Round 7 (2008-2012), Round 12 (2012- 2013), which was merged with the new funding model (NFM) 1 at the beginning of the second phase of Round 12 followed by the NFM 2 (2018-2020) and currently NFM 3 (2021-2023) is ongoing. The 5 year-Round based funding was for a period of 5 years divided into phase 1 (2 years) and phase 2 (3 years). Continued funding for phase 2 was subject to demonstration of good progress after phase 1. The NFM is for a 3-year period. Recently The Global Fund changed the name from NFM to Grant Cycles. The funding request for Grant Cycle 7 is underway and the submission of documents is on May 29, 2023. Below is the summary of the overall funding to WV for TB grant. Summary of the Funding Cycles, budget and number of implementing partners. Funding Cycle Period Budget(US$) Number of Implementing partners 1 R3 2004-2008 13.6 13 2 R7 2008-2012 17.7 24 3 R12 2012-2013 18.29 16 4 NFM1 2014-2017 35.95 14 5 NFM3 2018 -2020 22.94 12 6 NFM6 2021-2023 30.9 7 Cumulatively, more than $131 million was committed to Somalia programme.as been disbursed.
III. IMPLEMENTATION World Vision Somalia has been principal recipient (PR) of the Global Fund TB Control program since 2005, partnering with the Ministry of Health and implementing partners to deliver the TB control services across Somalia and Somaliland. The role is in line with the WV mission of serving the marginalised and poor communities since TB affects the vulnerable and poor persons disproportionately. Being PR, WV has the overall responsibility of program management, including financial management, capacity building, procurement and distribution of program supplies, implementation, supervision, monitoring and evaluation, reporting to the donor, and risk management and annual external audits. Currently there are 108 TB management units in 78 out of 90 districts in the country. This number is sub optimal to WHO recommendation of 1 TBMU/100,000. Plans to expand coverage are in place. The current coverage is 1 TBMU/157,000. The TBMUs ranges from the basic facilities equivalent to primary health units offering diagnostic and treatment services to large hospitals with admission / inpatient capabilities. More than 50% of the TBMUs offer integrated health services. Staff working at TBMUs are government staff but WV provides salaries from the GF grant. In addition to the role of PR, WV implements directly in 18 TBMUs as follows: 1. South West State: Afgoye; Baidoa, Barawa, Bayhawa, Burhakaba, Tiyeglow and Wajid. 2. Puntland: Dhadhar, Eyl, Garowe, Jariban and Qardo. 3. Somaliland: Badan, Balaygubadle, Gabiley, Hargeisa TB Hospital, and Hargeisa MDR Hospital. 4. Hirshabelle State: Jowhar. 5. Jubaland: Dolow Further TBMUs and implementing partners details are included in Annex 1. In order to monitor the program effectively, WV uses a third-party monitor (TPM) that works very closely with the M&E team. The TPM prepares the monitoring and evaluation schedules on quarterly basis with a target of visiting at least 80% of the TBMUs per year. The main areas of focus by the TPM are data quality checks, observation of the standard laboratory and clinical procedures, supply chain management including reconciliation of supplies, physical infrastructure and overall client satisfaction. The quarterly reports include recommended actions, and WV follows up on implementation of the action plan.
Figure 1: Distribution of TBMUs For effective TB services, the program has several initiatives. These are: 1. Outreach Services: Health workers visits populated location s such as IDP camps, slums and prisons to increase awareness on TB, conduct screening for TB using simplified questionnaire and looking at basic signs. Presumptive TB cases are referred at TBMUs for further testing. 2. Contact tracing: For every TB patient, the health workers visit and screen the immediate contacts, usually family members for symptoms and signs of TB using a simple questionnaire. Persons presumed to have TB are referred to the TBMU for investigations. Those testing positive for TB are treated while preventive treatment is provided to those testing negative. This is one of the most effective way of tracing TB patients and also
preventing transmission of the disease. This initiative has been done for MDR TB patients and to a limited number of drug sensitive TB patients. It will be scaled up in future. 3. Partnering with private sector: It is estimated that 60% of Somalis seek health services in private facilities. In order to increase TB case detection, the grant has partnered with the private health service providers. Some facilities conduct screening for TB and referral of suspected TB services to TBMUs for testing. Some facilities with more capacities provide diagnostic and treatment services. The grant provides training, equipment and drugs. 4. Using technology for efficient diagnosis: (a) GeneXpert: After WHO recommend use of rapid molecular diagnosis for, the grant procured GeneXpert machines for diagnosis. Currently there 105 GeneXpert equipment. The equipment is also used to test Multi Drug Resistant TB. Figure 2: Distribution of GeneXpert machines (b) Digital Mini X-ray equipment: The program procured 28 mobile mini X-ray to conduct screening for TB. The equipment has been used in some outreaches where screening is done in addition to awareness raising. Recently, the program initiated use computer aided detection for image interpretation with artificial intelligence providing diagnosis remotely on images that are uploaded on cloud platform. This has increased efficiency in the context of limited specialists. (c) The program has also increased diagnostic capacity by procurement of several equipment such as Liquid Probe Assay at major reference laboratories. This capacity has been further boosted by Gene sequencing equipment supplied by WHO.
5. Sample transportation: Since not all TBMUs have the GeneXpert equipment, WVS mapped all service points and established a network of transportation of specimens from some TBMUs to the GeneXpert testing sites. 6. Female Health workers: To increase TB case detection, the programme engaged Female Health Workers (FHWs) since 2018, who visits the communities to raise awareness on TB, screen community members for TB and refer presumptive cases for testing at TBMUs. By the end of 2023, there will be 500 FHWs working with the TB grant. 7. Cross border initiatives: Due to migration of population, families including TB patients move across the borders in search of water and pasture, or patients seeking treatment. Countries neighbouring Somalia including Kenya, Ethiopia and Djibouti agreed to collaborate in provision of TB services. This includes harmonizing approaches, referral information of known TB patients and tracing of defaulters. WV works the Ministry of Health to ensure cross border collaboration. 8. Integration of TB services: Due to history of management of TB in Somalia, majority of services have been provided through stand-alone facilities. This has led to missing patients that attend the general health services. The programme started integrating the stand - alone facilities for provision of general health services, currently, more that 55% of the TBMUs offer integrated health services. Key initiatives currently on going. 1. Layering, Sequencing: Given the geographical footprint of the GF TB grant and network of international and local NGO partners, layering and sequencing has been commenced in order to leverage on other programmes implemented by World Vision in Somalia. This is expected to increase geographical coverage and reach more children and the most vulnerable including in the most difficult-to-access locations. This will also link beneficiaries who require additional support to relevant programs. Achievements: 1. TB case notification: Since the inception of the grant, more than 250,000 drug sensitive TB patients have been diagnosed and treated. This is equivalent to investigating and testing more than 2.5 million people. 2. Treatment Success Rate (TSR): Of the 250,000 patients that were treated, more than 90% are treated successfully, which is above the WHO threshold of 85%. Since every TB patient transmits to an estimated 5 persons, this treatment plays a major role in preventing spread of the disease. 3. MDR TB management: Somalia has one of the highest burden of MDR TB in the world. MDR TB services were initiated in 2013 in Hargeisa, and 2015 in Mogadishu and Galkayo. Due to the need, recently, WV and MOH has worked to decentralize MDR TB services. To decentralise the MDR TB management and bring the services closer to
people, new facilities were opened in Baidoa (South West State), Kismayo (Jubaland), Beletweyne (Hirshabelle), Dusamareb (Galmudug). Additional facilities were also opened in Garowe and Bosaso in Puntland and Burao in Somaliland. WV has worked closely with MSF Holland in Galkayo and MSF France in Hargeisa to deliver MDR TB services. 4. Diagnostic services: The program has established 3 National Reference laboratories in Hargeisa, Garowe and Mogadishu. These are rated Biosafety Level 3, and can carry out advance tests including handling bio hazardous agents. These laboratories offer training for 108 TB management units laboratories and also conduct quality assurance for microscopy, a service that was provided out of country until 2022. Impact of the TB grant: As a result of the interventions over the years, there are major achievements notably reduction of incidence of TB from 286/100,000 population in 2015 to 250/100,000 in 2021, and reduction of mortality due to TB was reduced from 76/100,000 population to 66/100,000 in 2021. Summary of the impact on TB epidemiology. Indicator 2015 2021 Incidence of DS TB /100,000 population 274 250 Incidence of MDR TB /100,000 population 29 12 Mortality due to TB 76 66 Number of TBMU 34 (in 2005) 108 Our geographical footprint and network of international and local NGO partners ensured that we delivered critical TB services to the most vulnerable including in the most difficult-toaccess locations. Some these services were: TB diagnosis, testing, treatment, care and management, monitoring and supervision of TB patients, TB contact tracing, training and skills transfer for over 200 health workers. The program was also a shining example of how technology is transforming TB services through its use of the GeneXpert machines aimed at rapid and accurate diagnosis of drug sensitive TB, and further improving the detection of Multi Drug Resistant TB. In 2022, more GeneXpert machines were procured to increase the number of rapid molecular diagnostic tests. It should also be noted that, that the number of TB tests conducted using GeneXpert machines increased from 46,800 in 2021 to over 60,000 in 2022. The program also uses mobile digital mini X-rays for TB screening. Due to the shortage of specialists to interpret images, computer aided diagnosis using artificial intelligence has been introduced and will be scaled up.
IV. OTHER KEY INTERVENTIONS 1. Emergency support to mitigate impact of drought: The displacement of the population caused by drought had major implication to the access of TB services and TB spreading. Existing TB patients had no choice but to move out from their current settlements in search of food, water and humanitarian assistance. In order to maintain TB services, WV mapped out the most affected parts of the country and planned for outreach missions to 3,374 camps that hosts about 3.9 million people using 69 outreach teams in Banadir Region, Gedo and Middle Juba Regions in Jubaland State, Bay and Bakol in South West State, Galgadud and Mudug Regions in Galmudug State, Bari and Nugal Regions in Puntland, Sool and Sanaag Regions in Somaliland; and Hiran in Hirshabelle State. The support also provides nutritional support in the form of cash transfers to 2817 drug sensitive TB patients, and 358 MDR TB patients for a period of 9 months. The budget of $2 million to implement emergency support was funded by the Global Fund and implementation is ongoing. 2. Impact mitigation of Covid -19 The Covid -19 pandemic which started in march 2020 had a negative impact on health services including TB program. Due to movement restrictions, there was limited access to diagnostic and treatment facilities. Patients on treatment were given medications twice a month and it was difficult to monitor adherence to treatment which was usually done on daily basis or at least on weekly basis. WV and partners secured a budget to decentralize some vital services, and strengthen diagnostic and patient monitoring services. This included procuring and deploying more GeneXpert machines, using of mobile application to monitor patient adherence to treatment and using of artificial intelligence to interpret Xray images. TBMU staff were also trained on infection prevention and control, and adequate personal protection equipment supplies were procured and distributed. Implementation is still ongoing. The total budget to for Covid-19 interventions is $2.5. V. THE FUTURE TB remains a major public health concern in Somalia. There is a need to invest more resources in order to accelerate the reduction of the disease in the country. The funding request submitted to the Global Fund in May 2023 will cover the period of 2024- 2026 with a budget of $27.4 million against $60 million required to implement the national TB Strategy. More innovative fundraising approaches are required to compliment the Global Fund support.