Viet Nam STOP-TB Partnership:

Building a Sustainable Response

Nguyen Dinh Huong1, Dinh Ngoc Sy2 Nguyen Viet Nhung2, Nguyen Ngoc Minh2

Bruce Struminger3, Cornelia Hennig4

November 15, 2012 Kuala Lumpur, Malaysia

1. Chair of VSTP 3. Former Co-Chair VSTP 2. Vietnam NTP 4. Co Chair VSTP

Vietnam STOP-TB Partnership: Outline

1. Country background information 2. TB epidemiology 3. Challenges 4. National partnership introduction 5. Partnership principal activities 6. Conclusion

1. Country Background Information

• Area: 330.957 km2 • Distance: >3.200km, borders with

China, Laos & Cambodia • Population: 89 million (2011)

• Rural: 59,952 million (68,25%) • Urban: 27,888 million (31,75%) • Average density: 265/km2

• Administration • Provinces: 63 • Districts: 698 • Communes: 11,121

• LLMI country since 2010: $1,411 GDP per capita (2011)

2. TB epidemiology in Viet Nam

• Ranks 12th among 22 TB high burden countries.

• Ranks 14th among 27 countries with high burden of MDR-TB.

• TB prevalence in Viet Nam remains high. National prevalence survey (VINCOTB-06) showed that the previous estimation was underestimated by 60%.

A significant number (~40%) of tuberculosis cases remain undiagnosed or unreported.

40% ? Too difficult, …

TB epidemiology in Viet Nam 2006 ( WHO Report - 2008)

Incidence all cases /100.000 173

Incidence new AFB (+) /100.000 77 114 (Prevalence new AFB (+) -VINCOTB-06)

Prevalence all cases/100,000 225

Prevalence AFB (+) /100.000 90 145 VINCOTB-06

TB mortality /100.000 23

Of new TB cases, % HIV (+) 5.0%

Of new TB cases, % MDR-TB 2.7%

Of previous treated TB, % MDR-TB 19%

TB case notification

200 000

400 000

600 000

800 000

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

# su

spec

ts/s

s+ c

ases

0

10

20%

posit

ivity

# suspects# ss+ TB cases%positivity

Notification trend 2000-10, Viet Nam

Number of suspect screened 2000-09, Viet Nam

NTP End term Evaluation 2007-2011.

3. TB Response Challenges: human and financial resource, programmatic

• Human resources – Stigma, low financial compensation, and perceived risk

affect recruitment; lack of sufficient staff results in over-work; in combination these result in high staff turn-over

– Need for training on new approaches and techniques

• Financial resources – GVN budget: grossly insufficient, barely covering DOTS – Heavy dependence on external funding for PMDT, TB/HIV,

PPM, ACSM, high risk groups in context of rapidly decreasing funding

– New diagnostic tools: promising but expensive

Funding levels & gaps, 2013-15 (1)

Financial Need (USD) 2013 2,014 2,015 Total

Objective 1: High quality DOTS 48,557,537 54,067,373 49,350,967 151,975,876

Objective 2: TB/HIV, MDR-TB, Closed settings 6,449,221 7,254,870 8,267,339 21,971,429

Objective 3: HSS 3,445,845 4,310,847 4,487,344 12,244,036

Objective 4: PPM 2,814,085 2,164,900 2,154,153 7,133,138

Objective 5: ACSM 4927475 4934582 4633739 14,495,796

Objective 6: Surveillance and research 393,000 1,577,764 435,000 2,405,764

Total (in US$s) 66,587,162 74,310,335 69,328,542 210,226,039

Funding levels & gaps, 2013-15 (2)

Financial Gap (USD) 2013 2014 2015 Total

Funding needs 2011-2015 66,587,162 74,310,335 69,328,542 210,226,039

Estimated fund

Central Gov’t budget 5,500,000 6,000,000 6,500,000 18,000,000

Provincial Gov Fund 4,741,607 5,435,115 6,152,621 16,329,343

Global Fund 10,503,688 10,616,383 11,495,842 32,615,913

TB CARE I (PEPFAR) 3,900,171 3,900,171 3,900,171 9,600,342

EXPAND TB In-kind n/a n/a

CDC (PEPFAR) 293,000 293,000 293,000 879,000

Total in US $s 24,938,466 26,244,669 28,341,634 79,524,769

Funding Gap, US $s 41,648,696 48,065,666 40,986,908 130,701,270

Programmatic challenges

Challenge Intervention Ss(-) & EPTB increase HIV/TB Relapse/failure/default cases & reTx after default increase

DOT / PMDT

High CNR + poor Tx outcomes in congregate settings

TB control in congregate settings

High Tx success rate, but high prevalence rate and ~40% incident cases untreated each year

+ PPM

Very low CNR among children less than 14 years Childhood TB control

Strengthening of recording/reporting

Programmatic challenges

Challenges Response Reduced international financial support Advocacy Cross-cutting issues of MDRTB, TB/HIV, PPM, closed settings … requires broad engagement of non-NTP partners

Partnership

Diagnostic delay for susceptible and resistant TB, suboptimal treatment adherence

New diagnostic tools, decentralization, shorter regimen, addl community engagement

Access barriers in mountainous areas ACF, ACSM, community DOT

SLD management Drug supply & Forcasting

Shortage of HR More incentives ($, training)

Accessibiltity (Patient charge) + Health insurance

4. VSTP Establishment & Sustainability

Initial concept and reason for formation: 2008, realization that an effective national TB response required significantly increased engagement and coordination of all stakeholders in TB control, including GVN and non-GVN partner organizations and the community at large Practical goal to significantly increase case finding and develop and ensure a sustainable TB response that is more patient-centred, community-based, engages the private sector, and includes PAL

First formal VSTP meeting: April 2010, followed by regular quarterly meetings Strong support from MOH and local partners, now over 39

VSTP establishment (cont’d)

Host organization and legal status: Vietnam Association Against TB and Lung Diseases - VATL

Unique strength: mass organizations with high potential for ACSM at the community and household levels and political leverage at the national, provincial, local levels

Women’s Union, Farmers’ Union, Youth Union, Red Cross, Veteran AssociationH

VSTP’s Partners

Partners # members National Lung Hospital / NTP

WHO – Vietnam Office

Women’s Union ~ 14 million

Farmers’ Union > 10 million

Red Cross > 10 million

Youth Union > 6 million

Veteran’s Association > 3.5 million Other NGO/CBO/Academic and bilateral/multilateral organizations: Vietnam Association Against Tuberculosis and Lung Diseases, CDC, USAID, KNCV, MCNV, PATH, URC, FHI, PSI, University of California San Francisco, Woolcock Medical Research Institute

Other VN government organizations: Ministry of Health, Ministry of Public Security, Ministry of Labour-Invalids and Social Affairs, Ministry of Education and Training, Viet Nam Administration of HIV/AIDS Control, National Institute for Hygiene and Epidemiology

Private sector: Ha Noi Association of Private Medical Practitioners, Hai Duong Association of Private Practitioners, Hung Thinh Pharmaceutical and Medical J.S. Company, METRO Cash & Carry Company

5. VSTP Primary Activities

Advisory role to NTP on technical and policy issues for TB control in Vietnam

Information sharing and improved coordination and collaboration

Support to NTP in developing and implementing solutions for challenges Initial priority focus to develop ACSM and PPM advisory networks among VSTP partners Financial and technical resource mobilization from local and international organizations Quarterly full partnership meetings, TWG meetings, ad hoc one-on-one meetings

VSTP Activities-highlights

GR R9 proposal development NTP 2007-2011 mid-term & end-term evaluations GR R9 Phase 2 proposal development National Strategic Plan for Tb control 2011-15 National Strategy for Tb control to 2020, vision 2030

VSTP Activities-highlights

Partners 2012 TB Month Activities

National Lung Hospital National Tuberculosis Control Program

•Mass media campaign on national and local television channels and newspapers

• 2 documentary films on NTP achievements from 2007-2011 and Contribution of the Royal Netherlands for TB control in Vietnam

• Photo and publication exhibition • In collaboration with Post and Telecommunication

Corporation: issuance of stamp set "For a Vietnam Free of Tuberculosis"

World Health Organization – Vietnam Office

• Journalist competition with more than 100 entries on TB control. Award ceremony is scheduled to take place in May, with free TB consultation and a performance show

•Media photo contest on TB control

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VSTP Activities-highlights

Partners 2012 TB Month Activities

Women’s Union

• Performance Festival for all levels of NTP and mass organizations. Final event held March 23, 2012 with participation of ~200 staff from Lung and TB hospitals, Farmers' Union and Women's Union

Youth Union • TV talk show with 70 outstanding youth delegates from 10 provinces and cities

Red Cross

• Meeting for community health with participation of Deputy Prime Minister, MOH leaders and ~5000 individuals

• Blood donation campaign for TB patients • Live broadcast TV program on national television • Gift packages for 50 low-income TB patients

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5. Conclusion

1) The Vietnam National STOP-TB partnership is a critical element in the strategy to achieve maximally effective TB control in Vietnam and offers a catalytic mechanism for achieving TB control 2) How to build STOP-TB partnership? The NTP remains CORE; importance of creating an environment of inclusion (active solicitation of input from all members, as a group and as individuals), transparency, mutual benefits, and responsibilities 3) How to make it sustainable and effective? Advocacy, ACSM, as the primary mission, mechanism offering an environment and opportunity for partners to share experience, knowledge, ideas, finances, and sweat equity 4) The VSTP is a young partnership that has matured rapidly, but remains in a process of evolution -PPM and ACSM TWGs already active, other TWGs in process of formation -VSTP continues to expand with new partners while keeping old partners engaged

On behalf of the Viet Nam National STOP-TB Partnership: