GLOBAL FUND-SUPPORTED

PARTNERSHIPSDO THEY WORK IN FAILED STATES?

WV SOMALIA TB PROGRAM EXPERIENCE

By

Dr Vianney Rusagara, MD - World Vision Somaliaand

Dr Milton Amayun, MD - World Vision International

Somalia - Country profile

• Located in the horn of Africa• Country with the longest seacoast in Africa -

3,000 km (Red Sea and Indian Ocean)• Total area - 638,000 sq.km • Population - 7.96 million • Mostly semi-arid and desert • Harsh environment, favours nomadic lifestyle• One tribe, one language• One religion (100% Muslim)

Somalia

Somalia

Political situation• No unified government for the last 15 years• 3 distinct geopolitical and autonomous zones

(Northwest, Northeast, South/Central)

• Northwest (Somaliland) declared as a break away republic in 1991

• Northeast (Puntland) 1998• Traditional governance used in some areas• Warlords control some areas of South/Central

Somalia

Geopolitical subdivisions

North West (Somaliland)

North East(Puntland)

South/Central

Somalia …..….is

mainly arid

some areas have

water – especially

the south

Effects of long conflict• The prolonged civil war destroyed health and

social service infrastructure• Most parts have been under a complex

humanitarian emergency• Health sector probably the most affected• Infectious diseases are prevalent• TB - among top 3 public health problems• Services mainly by INGOs and UN agencies

Effects of conflict…..

Vulnerable displaced

population

Effects of conflict….

Many major towns

were left in ruins

Some towns needed to be restored

Current health indicatorsInfant Mortality Rate 130/1000 live births

Under 5 mortality Rate 219 /1000 live births

Maternal mortality Ratio 1,600/100k (2004)

Life expectancy at birth M/F: 43/45 (years)

BCG coverage - 1 year old 35% (2006)

Measles coverage - 1 year old 22% (2006)

TB Incidence 372/100,000

HDI 0.299 (2005)

Purchasing Power Parity $600 (Rank: 193)

Somalia TB Program

• Reactivated in 1995 by WHO and NGOs

• Funding entirely external

• By 2002, there was a good foundation

• Further expansion required more funds

• 2003: a 5-year proposal for TB control was approved by the Global Fund

Global Fund TB Program

• Multi-partnership – 10 INGOs, WHO and local organizations, governments – MOH, a private firm, multilateral agencies

• Somalia Aid Coordinating Body = CCM

• Most activities based in Nairobi

• WVI - Somalia selected Principal Recipient to replace WHO.

Program Goal and ObjectivesGoal

To decrease TB

morbidity and mortality

Main Objectives

1. Increase access to TB services

2. Improve quality of the program with treatment success rate > 85%

TB Patients…

Some patients present at late stages with complications

Main Activities

• Support essential Human Resource

• Improve infrastructure and provision of essential equipment

• Training/Planning

• Procurement and distribution of drugs and lab supplies

Main Activities….

Training

Health workers at end of trainingsession

Main Activities....

• To strengthen TB Information System

• Produce/Distribute Information Education and Communication (IEC) materials

Main Activities….• Monitoring and

Evaluation: Close supervision and

monitoring Microscopy quality

control Quarterly and Mid-Year

Program Reviews Operational research,

external annual audit / evaluationSupervision and monitoring team

with some staff at a TB facility

Awareness raising and Health Education

Health education is conducted before dispensing anti TB drugs to patients

Mobilization and awareness on TB (and HIV/AIDS) in a community

Program Budget

Phase 1: 2years (Oct 2004 – Sep 2006) - US$ 8,224,136

Phase 2: 3 years (Oct 2006 – Sep 2009) - US$ 8,224,136

Implementation arrangements

• Roles of partners clearly defined• WHO – technical advice, training, research• WV - overall program management• Supervision/M&E - WV assisted by an

INGO with national program coordinators• Coordination team chaired by WV• Program data recorded and reported using

standard WHO information system on TB

Program partners’ architecture

Global Fund

Local Funding Agent(PricewaterhouseCoopers)

CCM (HSC)

TBCT(Technical and Management)

TB WG(Coordination Forum)

TB PROGRAMSub recipients

Principal Recipient

(World Vision)

ECHO

Community/Other partners WFP

Ministries of Health

Reports

Food

Reports Funds,Monitoring

Logistics

MonitoringPolitical support

Funds,Monitoring

Reports

Reports

Information

Coordination

Reports

Monitoring

Reports

Oversight

CCM - Country Coordinating MechanismHSC - Health Sector CommitteeTBCT - TB Coordination TeamTB WG - TB Working GroupECHO -EC Humanitarian Office

TB Treatment facilities before Global Fund support (at end 2004)

TB Treatment facilities opened with GF Fund support (at end 2006)

Program Results - Case notification

Case detection increased

49% (2004) to 60% (2006)

Somalia TB Program - Case notification Trend

TB Case notification trend 1995 - 2006

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Nu

mb

er o

f p

atie

nts

SS+ve

SS-ve

Expulm

Relapse

Somalia TB Program - Case notification Trend

TB Case notification trend 1995 - 2006

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Nu

mb

er

of

pa

tie

nts

Relapse

Expulm

SS-ve

SS+ve

Somalia TB Program - Case notification Trend

Somalia TB ProgramCase detection rate 2000 - 2006

0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006

Year

Ca

se

de

tec

tio

n i

n %

Program Results Treatment Outcome

Treatment success rate ca. 90%

Somalia TB Program Treatment Outcome1995 - 2005

Somalia TB Program Treatment Outcome 1995-2005

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er o

f p

atie

nts Cured

Completed

Died

Failure

Defaulted

Transfer

Somalia TB Program Treatment Outcome1995 - 2005

Somalia TB Program-Treatment Outcome 1995-2005

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er o

f p

atie

nts Cured

Completed

Died

Failure

Defaulted

Transfer

Somalia TB Program Treatment Outcome1995 - 2005

TB Treatment Outcome: 1995 - 2005

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Tre

atm

ent

ou

tco

me

(%)

Tr. Success

Death

Failure

Defaulter

Transfer

Linear (Tr. Success)

Linear (Failure)

Other Results…….

• Results in almost all the indicators - above targets

• Tuberculin survey – Incidence decreasing

• Phase 1 GFATM evaluation awarded an “A”

Impact of the Global Fund Program

• Global Fund has enabled continuity of TB service in Somalia

• There are remarkable achievements in a short time

• Program staff supported

Impact of the Global Fund Program

• Coordination for a has brought together the Ministries of the 3 (sometimes) warring authorities

• Cured patients have become advocates and stigma has drastically reduced

• Given Hope to very poor communities. • Set an example to many other programs

in Somalia.

Coordination

Mid term review: Donor (GFATM),Private,Multilateral,Government Authorities, Civil society partnersrepresented

Challenges

• Geopolitical divisions

• Insecurity, limited access to some areas

• Mobile populations

• Limited resources – some gaps

• Weak health delivery system

• TB / HIV

• Multi Drug Resistance

On faith issues…• WVI is well known as a Christian INGO.

• The combination of professionalism and longevity in Somalia was its platform to work on a nationwide TB program.

• Respect for Islam, sensitivity to local practices and definitely no proselytism.

• Key: Transparency, openness and frequent consultations are the key

• Plus: Caring staff in a harsh environment.

Lessons learned… What did not work well

Due to multi-partner nature:• Initial misunderstanding on roles

and responsibilities – detailed TORs needed!

• Local authorities: control issues. • Supervision/Monitoring teams

denied access in some areas.

“These were resolved through constant dialogue and coordination”

Lessons learned ….What worked well

• Partners should be well chosen for complementary strengths.

• Country program decisions on TB taken jointly in a pre-agreed upon process.

• Corrective accountability: solve problems immediately – before they become crises.

• Performance-based concept works in fragile/failed states as in stable countries.

Conclusion…..

“When resources are available, well designed and implemented programs by

professional and caring staff can succeed anywhere - even in FAILED states.”