South Africa

CCM Request for tb Funding

31 May 2013

General Programme Information

Applicant South African Global Fund Country Coordinating Mechanism

Country South Africa

Component TB

Implementation Period start date Click here to enter text.

Implementation Period end date Click here to enter text.

Principal Recipient (PR) Name / Grant/SSF Number / Grant/SSF start date
PR 1 - National Department of Health (NDOH) / SAF-H-NDOH / 1 July 2011

CCM Approval of Request for TB Funding

Role / Name / Title / Organization /
CCM Chairperson / Dr. Fareed Abdullah / South African National AIDS Council (Chief Executive Officer)
CCM Vice Chair Person(s) / Mr. Tshiamo Moela / South African Men Action Group (SAMAG) (Civil Society Representative)
Civil Society / Mr. Brian Kanyemba / Desmond Tutu HIV Foundation, University of Cape Town
Mr. John Mkandawire / Wits Reproductive Health Institute
People Living with HIV / Mr. Beau Nkaelang / National Association of People Living With HIV/AIDS
Ms. Portia Ngcaba (Note-recently appointed in May as previous member resigned) / Treatment Action Campaign
Government Departments / Mr. Leon Swartz
Alternate: Ms. Dikeledi Johanna Nkau / Department of Social Development
DR Ramneek Ahluwalia
Alternate: Mr. Chief Mabizela / Department of Higher Education
Ms. Thandeka Mxenge
Alternate: Mr. France Sesedinyane / Department of Women, Children & People with Disabilities
General Edna Joseph / Department of Defence
Dr. Faith Kumalo / Department of Basic Education
Head of Secretariat: Provincial Council on AIDS (PCA) / Ms. Marlene Poolman / Western Cape PCA
Prof. Kallie Snyman / North West PCA
Ms. Khunjulwa Makatesi / Northern Cape PCA
Ms. Aldina Ntsewa / Limpopo PCA
Mr. Charles Magagula / Mpumalanga PCA
Dr. Fikile Ndlovu
Alternate: Ms. TN Ngwenya / KwaZulu-Natal PCA
Dr. Elizabeth Floyd / Gauteng PCA
Mr. Tefo Tabi
Alternate: Ms. Shirley Hugo / Free State PCA
Mr. Vuyisa Dayile / Eastern Cape PCA
Private Sector / Mr. Louis Hollander / Road Freight Employers Association
Ms. Kasthuri Soni / South Africa Business Coalition on HIV and AIDS (SABCOHA)
Dr. T Balfour-Kaipa / Chamber of Mines
SANAC Costing Technical Task Team / Ms. Teresa Guthrie / Centre for Economic Governance and AIDS in Africa (CEGAA)
Mr. Stephen Cohen / Strategic Development Consultants
Development Partners / Dr. Catherine Sozi
Alternate: Dr. Sarah Barber / UNAIDS / WHO
Mr. James Maloney
Alternate: William Abrams / PEPFAR
Dr. Bernd Appelt / GIZ (representing the EU Constituency)
Labour Union Rep / TBD
EX-OFFICIO MEMBERS
Principal Recipients / Dr. Yogan Pillay
Alternate: Ms. Sesupo Makakole-Nene / National Department of Health
Prof. Keith Househam
Alternate: Ms. Juanita Arendse / Western Cape Department of Health
Prof. Ian Sanne
Alternate: Dr. Pappie Majuba / Right to Care
Ms. Marieta De Vos
Alternate: Dr. Maureen Van Wyk / Networking AIDS Community of South Africa
Dr. Renier Koegelenberg
Alternate: Mr. Charl Fredericks / National Religious Association for Social Development
Local Fund Agent (LFA) / Ms. Roshantha Govender / KPMG
Ms. Wanda Beukman / KPMG
Ms. Kashmira Bhana / KPMG
SANAC Secretariat / Dr. Nevilene Slingers / SANAC: Manager: Funding and Donor Co-ordination
Dr. Miriam Chipimo / UNAIDS
Ms. Celicia Serenata / CHAI

The contact details of the GF CCM members are also available on the SANAC website: www.sanac.org.za.

The signatures of approval are to be found as an Annex. The TB proposal was approved at the recent GF CCM meeting on 28 May 2013. The vote to accept the proposal was unanimous and Ms Marlene Poolman passed the motion to accept the proposal and Ms Khunjulwa Makatesi seconded this.


PROPOSAL SUMMARY

According to the World Health Organization (WHO), South Africa’s combination of high TB, HIV and MDR-TB burden is one of the most unique and challenging TB control situations in the world. This proposal calls for the creation of a 55 million US dollar programme that will create an opportunity for South Africa’s MDR treatment programme, the second largest in the world, to become a well- functioning flagship service. The programme will be achieved through decentralisation of treatment initiation to district and case holding to sub-district and ward levels with active defaulter tracing. MDR-TB treatment will thus be integrated with the decentralised nurse initiated antiretroviral therapy services. The programme will also directly support the annual screening for TB and HIV of a quarter of a million people in special risk populations in correctional centres and in peri-mining communities. Monitoring of services providing access for more than 400,000 miners to regular TB prevention, screening and treatment in the mines of South Africa will be expanded.

1. MDR-TB: 15.9 million US dollars (29% of the funds) will be spent on improving access for underserved MDR-TB patients by decentralising treatment initiation in the country from 31 to all 52 districts in the country and increasing treatment service points from under 100 to 2500 sites, through the existing PHC ward based teams. This will happen through a rapid establishment and scale up of nurse led MDR-TB treatment management teams at ward level as proposed by the NSP. Treatment initiation rates will resultantly increase from 56% to over 75% by March 2016 bringing on average an additional 3000 diagnosed MDR-TB patients under treatment. The MDR-TB component will also improve quality of service through defaulter tracing, increasing XDR TB diagnostic capacity in the 11 centres of excellence and strengthening MDR-TB contact tracing mechanism.

2. Correctional Facilities: 19.7 million US dollars (36% of the funds) will be spent on improving TB control in all 242 correctional centres ensuring access to regular TB and HIV screening and treatment of up to 150,000 inmates as per guidelines for management for TB and HIV in correctional facilities. TB and HIV awareness efforts in correctional centres will be enhanced, and X-ray and TB data-management capacity will also be strengthened. Infection control interventions will include training of correctional focal persons and risk assessments from which plans will be developed to be implemented by government.

3. Peri mining communities and mines: 14.7 million US dollars (27% of the funding)) will be used to target the vulnerable peri-mining communities (estimated at around 600,000 people) in 6 main mining districts. Tailored same-day TB/ HIV screening and diagnostic services using 12 mobile units with evening and weekend opening hours will be provided. Confirmed cases with be linked to care. In addition the Department of Health will support the Department of Mineral Resources and other statutory agencies to monitor compliance to applicable laws and regulations in the mining industry including the requirement for regular screening for TB and HIV and provision of access to treatment for about 400,000 miners in the country.

4. Enabling environment: 4.5 million US dollars (8% of the funding) will be allocated to strengthening programme management and monitoring and evaluation of the principal recipient and sub recipients.

General Programme Information 2

CCM Approval of Request for Interim Funding 2

PROPOSAL SUMMARY 5

Acronyms 7

Section 1: Country Context and Program Performance 8

1.1 Country Context and Epidemiological situation 8

1.2 Program performance 16

Section 2: Planned Activities for the Implementation Period 24

2.1 Analysis of targets, resource needs and gaps for the implementation period 24

2.2a Proposed activities for the implementation period 33

Section 3: Eligibility Requirements, Partnerships and Management Risks 46

3.1 Counterpart Financing Requirements 46

3.2 Focus of Proposal Requirement 48

3.3 Partnerships 49

3.4 Grant Risk Management 50

Section 4: Financial Request 52

List of Annexes 54

Acronyms

ART / Antiretroviral therapy
c.i. / Confidence interval
CCM / Country Coordinating Mechanism
CDC / Centers for Diseases Control and Prevention
DCS / Department of Correctional Services
DHIS / District health information system
DMR / Department of Mineral Resources
DOTs / Directly observed treatment support; basic package of TB services that underpins the Stop TB Strategy
EDRweb / Electronic Drug Resistance Web
EQA / External Quality Assurance
ETR.net / Electronic TB register
HCT / HIV counselling and testing
HDI / Human Development Index
HIV / Human Immunodeficiency Virus
HIV GF SSF / HIV Global Fund Single Stream Funding
IEC / Information Education and Communication
IPT / Isoniazid prophylactic therapy
LFA / Local Fund Agent
LPA / Line Probe Assay (LPA)
MDR-TB / Multi-drug resistant tuberculosis
mHealth / Mobile Health
NHI / National Health Insurance
NHLS / National Health Laboratory Services
NIMART / Nurse-initiated and managed ART service
NIMDR / Nurse-initiated and managed MDR-TB treatment
NSP / National Strategic Plan
NTP / National Tuberculosis Programme
PEPFAR / Presidents Emergency Plan for AIDS Relief
PHC / Primary Health care
PLHIV / People living with HIV
PMU / Programme Management Unit, within the NDOH
SADC / Southern Africa Development Community
SDA / Service Delivery Area
SMS / Short Messaging Service
STATSSA / Statistics South Africa
STI / Sexually Transmitted Infections
TB / Tuberculosis
WHO / World Health Organization
XDR TB / Extensively drug resistant TB
Xpert MTB/RIF / Molecular test for Mycobacterium tuberculosis and rifampicin resistance using the GeneXpert platform (Cepheid, USA)
/

Section 1: Country Context and Program Performance

1.1 Country Context and Epidemiological situation

Please briefly describe any changes to the disease epidemiological situation and the country context that is likely to affect program implementation or strategies. Please also comment on the population size, disease burden and mortality (where data is available, disaggregate the data by age, sex, and key populations, as necessary).

National Structure and Population Size

South Africa is a democratic state with government functions organised at three levels, namely, national, provincial and local (the latter with coterminous boundaries between district and municipality authorities). Health policy and legislative development are national functions while provinces are responsible for operational service delivery, mainly through district and local government entities, including clinics and hospitals. The division of responsibilities for health delivery, although intended to meet an important constitutional requirement for devolution of responsibility to lower levels of the system closer to users of services, has in some instances given rise to poor coordination and incoherence in health service delivery between and among national and provincial health authorities.

The recent population census by Statistics South Africa (STATSSA) established South Africa’s population to be just under 52 million (see Table 1) with Gauteng province having the largest share (23.7%) and the Northern Cape being the least populated (2.2%).

Table 1: South Africa’s population size and provincial distribution
Province / Population Size / Percentage
Eastern Cape / 6,562,053 / 12.7%
Free State / 2,745,590 / 5.3%
Gauteng / 12,272,263 / 23.7%
KwaZulu Natal / 10,267,300 / 19.8%
Limpopo / 5,404,868 / 10.4%
Mpumalanga / 4,039,936 / 7.8%
North West / 3,509,953 / 6.8%
Northern Cape / 1,145,861 / 2.2%
Western Cape / 5,822,734 / 11.2%
South Africa / 51,770,734 / 100%

Source: Census 2011, Statistics South Africa

Epidemiological Profile of TB and TB/HIV

South Africa is regarded as a middle income country, and yet, as a result of socio-economic inequalities and uneven development, as indicated by its Human Development Index Ranking 121 (HDI)[1], first and third world conditions co-exist alongside each other in the country. Resultantly, TB and HIV, diseases strongly associated with poverty and under-development, have reached epidemic proportions. Among the WHO 22 TB high burden countries (responsible for about 80% of the global TB cases), South Africa’s TB prevalence and incidence rates rank second and first respectively[2]. The TB incidence rate for the general population in 2011 is estimated at 993/100,000, the second highest globally, indicating that almost 1% of the South African population develop the TB disease every year (see Table 2)[3].

The country also has the world’s largest population of people living with HIV and the high TB burden is largely a result of the interrelationship between HIV and TB (see Figure 1). The rise in TB incidence occurred in the late 1990s following the rise in antenatal HIV seroprevalence by approximately five years. The number of cases detected for all forms of TB steadily increased from 207,441 in 2000 to 406 082 in 2009 and has fallen back to 389,974 in 2011.

Figure 1: Relationship between national TB incidence (left axis) & HIV seroprevalence (right axis) in South Africa 1990-2010 (National Department of Health -NDOH)

The latest published national mortality data (from vital registrations) show that tuberculosis caused 12% of all deaths in 2010 and remains the commonest cause of death among all South Africans.[4]

Although estimated TB mortality rate among HIV negative patients is also showing marginal reductions since plateauing between 2009 and 2010 at 50/100,000, the rate remains high at 49/100,000 in 2011[5].

Table 2: Summary of key impact indicators
Estimates of TB Burden 2011 / Number / Rate per 100,000 population
Mortality (excludes HIV+ve TB) / 25,000 / 49
Prevalence (includes HIV+ve TB) / 390,000 / 768
Incidence (includes HIV+ve TB) / 500,000 / 993
Incidence (HIV+ve TB only) 2010 / 330,000 / 650

Source: ETR.net and WHO TB Control Report 2012

South Africa had an estimated adult (aged 15–49) HIV prevalence rate of 17.9% with around 5.575 million adults and children living with HIV (11% of general population) in 2010. Of these, 518,000 were children under 15, 2.95 million were females aged 15 years and older, and there were almost 333,000 new HIV infections during 2010

The National Strategic Plan for HIV, STI and TB (2012-2016) (NSP) in addition identifies key populations for the TB response: health care workers, mine workers, correctional services staff and inmates; children and adults living with HIV; diabetics and people who are malnourished; smokers, drug users and alcohol abusers; mobile, migrant and refugee populations; and people living and working in poorly ventilated and overcrowded environments, including those who live in informal settlements.

For the purposes of this proposal we target three groups,

i) people living with multi-drug resistant TB

ii) inmates in correctional facilities

iii) miners and peri-mining communities

on the basis of these being underserved by available service provision and being key populations with high TB rates and important in the context of control of the TB epidemic.

Multidrug resistant tuberculosis (MDR-TB)

South Africa has an estimated 13,000 cases of MDR-TB, the highest burden of drug-resistant tuberculosis in Africa. The last drug resistance survey was carried out in 2002 and results from an on-going survey are awaited. Around 1.8% of new TB cases and 6.7% of retreatment cases have MDR-TB. South Africa has the 2nd highest number of MDR-TB cases on treatment (5,643 in 2011) globally (after the Russian Federation), however a significant proportion of the detected cases - 44% in 2012, are not enrolled on TB treatment (See Table 3). Although detection of MDR-TB is decentralised, the registration and treatment options are quite centralised. The lack of primary health care engagement with patient management contributes to the fact that only 42% of patients successfully complete treatment.