Southern Africa Tuberculosis and Health Systems Support Project

Objectives & Structure Informative • summarize the technical design and implementation arrangements Explorative • opportunities for strategic partnerships and innovation Practical • discussion on implementation issues (Governments, Regional Organizations, Bank and Partners)

MDG 6 TB target achieved TB EPIDEMICREVERSED Incidence rate 49 million lives saved between 2000 and 2015 Falling 1. 4% per year (2000 -2015). 18% drop since 2000 47% DROP IN TB MORTALITY Mortality Targe t 47% decline since 1990 But huge burden of deaths and suffering remains. 10. 4 million people fell ill with TB in 2015, and there were 1. 8 million deaths

Highest TB/HIV Co-infection Rates: 50 -77% Trends of Coinfection TB-HIV incidence in Southern African Countries 1200 Incidence per 100, 000 pop 1000 Botswana 800 Lesotho Malawi 600 Mozambique Namibia South Africa 400 Zambia 200 0 199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

Increased Risks of MDR-TB: Trans-boundary Effects, Costly and Higher Treatment Failure Rates

Underlying Issues in SADC – High Burden of TB • • • High burden of HIV/AIDS Underlying health systems weaknesses TB response, detection, and monitoring constrained by: § § weaknesses in occupational and mine-health regulations, unenforced legislation, poorly standardized treatment protocols, weak diagnostic capacity and services unavailability of skilled human resources for health (HRH), and inadequate financial resources. • Country TB control efforts – limited effectiveness in addressing high risk groups, i. e. mining communities • Complex relationship between mining, poverty and disease burden in SADC High burden of TB amongst mineworkers Migratory nature of mineworkers and resultant transmission of TB to families and communities around mines and labor sending areas • •

Summary of Proposed Approach

Main Rationale for Regional Approach q Word Bank’s commitment to supporting countries in the sub-region to tackle TB while strengthening critical dimensions of health systems. q POLICY HARMONIZATION: High levels of population mobility, porous borders, and regional and global communicable disease threats call for a highly coordinated and harmonized action q MARKET FAILURES & SPILL OVER EFFECTS: A coordinated regional approach is critical for activities with high spillover effects where individual countries may not have the incentives and resources to invest OR if one country does not manage a well, risks for neighboring countries is heightened q ECONOMIES OF SCALE: There is a potential to reap economies of scale through specialization, rather than developing all areas of expertise in each country q REGIONAL STEWARDSHIP: Opportunity to support regional institutions to synchronize policies and strategies; define a regional vision; and serve as a platform for knowledge generation and cross country learning

A new era with new ambitions and a paradigm shift UN Sustainable Development Goals: 2016 – 2030 17 goals and 169 targets

SDG 3 and its 13 targets by 2030 3. 1 Reduce Maternal mortality 3. 3 3. 2 Reduce child and neonatal mortality the epidemics 3. 3 End the epidemics of AIDS, tuberculosis, malaria & neglected tropical diseases and combat hepatitis, water-borne End of AIDS, and other communicable diseases tuberculosis , malaria 3. 4 Reduce 3. 5 Strengthen 3. 6 Reduce tropical mortality due to NCD & neglected Prevention and Mortality and improve mental diseases treatmentand of substance due to road traffic combat health abuse (narcotics, alcohol) injuries hepatitis, water-borne 3. 7 Universal 3. 8 Achieve and other communicable diseases 3. 9 Reduce access to sexual and reproductive health-care services 3. a Strengthen implementation FCTC (tobacco) universal health coverage 3. b Access to affordable essential medicines and technologies 3. c Increased health financing and health workforce in developing countries deaths and illness due to pollution and contamination 3. d Enhance capacity for early warning, risk reduction and management of national and global health risks

Global commitment to End TB Moving from halting TB to ending TB by 2030 SDG TARGET 3. 3 – BY 2030 END THE TB EPIDEMIC

Innovations and Research are critical to break the trajectory of the TB epidemic • • Better diagnostics, including new point-of care tests; Safer, easier and shorter treatment regimens for disease and latent TB infection; Effective pre- and post-exposure vaccines. All technological and system innovations possible

Proposed Technical Approach • Alignment with post-2015 global strategy for TB prevention, care and control • Broad areas • • Strengthening of integrated patient care and prevention Implementation of regional protocols and expanding supporting systems • Examples of Innovations and research – Mobile & electronic platforms e. g. use of mobile phones, management information systems, electronic medical records, etc. – Performance-based contracting (PBC) of non-state actors – Private sector focused models (win-win scenarios)

Builds on & Compliments Country and Regional Efforts Government Programs (TB, Mining & Labor) Bank Country Specific and Regional Investments • • • Development Grant Fund – Catalytic US$ 2 million DFID Trust Fund US$ 4 million Bank Projects for Country Specific Issues Global Fund country and regional • Global Fund Grant for TB in the Mines 10 countries – US$ 30 million • Global Fund Grant for Labs – 18 countries US$ 6 million Bilateral Programs

Summary of Design – Overall Objective Project Development Objectives: (i) Improve coverage and quality of key TB control and occupational lung disease services in targeted geographic areas of the four participating countries; and (ii) Strengthen regional capacity to manage the burden of TB and occupational diseases.

Targeted Approach Key criteria based on: • Geographic characteristics (mining/perimining) • A high burden of TB • Border regions/districts • Transportation corridors • High incidence of poverty & TB (where data available)

Overview – Component 1: Innovative Prevention, Detection and Treatment of TB • Subcomponent 1. 1: Enhance case detection and treatment success • Demand side interventions – community based targeting households, miners, caregivers • Improve the clinical quality and ensure International Standards for TB care across the four countries • Support to TB and MDR-TB patients e. g. nutrition, Anti-TB drugs • Performance based contracting (innovative TB interventions e. g. specimen transportation, results based funding for NGOs)

Component 1 continued… Sub Component 1. 2: Rolling out a standardized package of occupational health services and mining safety standards across the four countries • Strengthen government agencies capacity for mine safety – inspections on mine dust levels • Expanding periodic screening and referral of occupational lung diseases and other diseases e. g. Diabetes • Develop/strengthen occupational health databases and electronic record systems

Component 2: Regional Capacity for Disease Surveillance, Diagnostics, and Management of TB and Occupational Lung Diseases • Sub-component 2. 1: Improving quality and availability of human resources in the targeted areas • • • Development of a skilled health workforce based on a regionally defined curricula, mentoring and knowledge sharing in TB, mine health regulation/Occupational services and disease surveillance Address specific skills gaps i. e. co-management of HIV-TB; MDRTB; disease surveillance; occupational health; laboratory and diagnostics Support pre and in-service training, inter country exchanges, on-the -job technical mentorships

Component 2: Continued… Sub-component 2: 2 : Strengthening diagnostic capacity and disease surveillance • Partner with CDC, WHO and ASLM – Scaling up of Strengthening Lab Management Towards Accreditation (SLMTA) & SLIPTA • Rolling out newer and more accurate diagnostic technologies • Develop a mechanism for intelligence sharing on disease threats among participating countries • Networking of National TB laboratories and linkage to Supranational (e. g. Uganda SRL)and Regional Labs • Establish joint cross border committees for joint outbreak investigations and public health events

Component 2 continued… Sub-component 2. 3: Strengthening mine health regulation • Update or draft occupational and health safety legislation, guidelines and policies • Developing IT systems for compliance monitoring and mine health surveillance • Support mine health equipment and training • Developing/updating regional best practices guidelines on regulation and clear standards REL in large and small-scale mines • Capacity building of regulatory institutions to enforce mine health regulations

Component 3: Regional Learning and Innovation and Project Management Promotes regional innovation through sharing of knowledge, evidence from interventions implemented under components and 1 and 2, and activities supported under regional centers for excellence. regional baseline assessment reports that bring evidence to better define the context, and inform policy and project interventions; • in-depth case studies capturing the mechanism and outputs of innovations funded by the project; • south-south learning exchanges between policy makers and practitioners from the four countries and between them and other parts of the developing world with successes in TB, such as Peru; • rigorous process evaluation of interventions, subject to the feasibility of the design of the interventions. • a joint annual review and planning, which brings together the four project countries, will be undertaken and used as a platform to strengthen cross-country learning and promote innovative approaches.

Component 3 continued… Sub-component 3. 1: Operational research and knowledge sharing: Priority Research topics • • Impact evaluation of new diagnostics tools on health outcomes Mapping of mining activities within the participating countries In-depth case studies capturing the mechanism and effects of innovations funded by the project South–South learning exchanges between policy makers and practitioners from the participating countries and between them and other parts of the developing world with successes in TB, such as Peru

Component 3: Continued Sub-component 3. 2 Centers for Excellence in TB and Occupational Lung Disease Control Lesotho - community-based management of TB (use of digital mobile x-rays) Malawi - community TB care & integrated disease surveillance Mozambique - MDR-TB & childhood TB management Zambia - occupational health and safety.

Communities of Practice (Co. P) Five key areas: • Economics of TB control and sustainable financing • Service delivery: continuum of TB care across and within national boundaries • Research, and monitoring and evaluation (M&E) • Mine health regulation and occupational health • Diagnostics and surveillance of diseases

Example: Thematic Responsibilities for Learning and Knowledge Sharing UGANDA TANZANIA Training Lab Networking ECSA In collaboration with EAC KENYA O. R. Surveillance RWANDA ICT/MDR-TB PBF (jointly with Burundi) Empowering clients through access to knowledge

Component 3: Continued Sub-component 3. 3 Regional coordination, policy advocacy and harmonization • Support ECSA-HC and NEPAD to undertake regional activities – economies of scale, regional learning and knowledge exchange • Roles clearly defined • SADC coordination

Regional Advisory Committee (RAC) 28 To bring together the stakeholders working on the regional project to • provide strategic guidance and oversight functions • review implementation progress • strengthen the working relationships and partnerships opportunities in order to achieve the expected deliverables of the project • ensure coordination with other key initiatives Southern Africa TBHSS Project 9/13/2021

Membership q Permanent/Principal Secretaries of Health q Technical Departments Representatives (2) Implementing Ministries (3) Ministries of Finance q 1 representative from each MOF Non-State Actors q q q Zambia - Chamber of Mines Lesotho - Association of Miners Mozambique - NGOs/Civil Society Malawi - Labor Union Research Institution Other representatives (Ex officio) q q 1 Global Fund Regional Coordinating Mechanism 1 member from SADC Global Expert in TB control Technical Partners – CDC; WHO? Donor (Ex officio) Strategic partner/country representative 9/13/2021 Regional Coordinating q World Bank q Brazil q ECSA-HC q TBHSS NEPAD Southern Africa Project 29

Regional Advisory Committee (RAC) responsibilities 30 Convene stakeholders working to: • Endorse regional work plans and deliverables and inter-ministerial NTC • Review implementation progress • Review communities of practice annual work plans • Provide strategic guidance and oversight • Explore opportunities for new partnerships and advocacy for the project • Ensure coordination and alignment with other initiatives (ie the GF initiatives) • Follow up on Key research findings Southern Africa TBHSS Project 9/13/2021

National Technical Committees (NTC) • At country level the Inter ministerial NTC as main oversight governance committee • Composed of implementing ministries, partners and private associations (country specific) • Responsible for reviewing and approving consolidated work plans and budgets • the primary vehicle to coordinate stakeholder engagement and dialogue with regards to the project. • Platform for partners to report on experiences and lessons and to coordinate future interventions (TB, OSH, Lab, Mines etc)

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