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URC’s Commitment to Support USAID’s New TB Business Model, the “Global Accelerator to End Tuberculosis” in South Africa

USAID TB South Africa Project Achievements URC’s Commitment to Support USAID’s New TB Business Model, the “Global Accelerator to End Tuberculosis” in South Africa
Publication date: 
May 2019

University Research Company (URC) is a global health and development firm with over 53 years of experience in implementing clinical service delivery, systems strengthening, and quality improvement activities. With projects in over 45 countries, URC applies worldwide experience to approach these projects, understanding that work must consider global best practices while remaining locally-specific and contextually appropriate. 

URC has been a leader in the global fight against Tuberculosis (TB) and supports National TB Programs (NTPs) to achieve national goals to end TB. URC is excited about the launch of the new USAID TB business model, the “Global Accelerator to End Tuberculosis,” and plans to continue its commitment to support USAID efforts to end TB. URC plans to deepen our support for local governments, civil society, and communities while leveraging and fortifying existing capabilities and resources, scaling up and institutionalizing effective high impact practices, and prioritizing governance and leadership, to help countries achieve sustainable self-reliance for improved health outcomes for their people.

URC’s ongoing work dovetails well with the new TB business model objectives, including leveraging additional resources from countries, engaging private sector partners, and engaging local organizations to increase the number of people living with TB who are on treatment. URC also leads public-private partnership efforts to end TB in various countries under many USG funded programs helping local partners to achieve a self-reliant health system. URC has successfully managed small grants programs valued at over $100M, which engage and capacitate local NGOs and CSOs in the TB response and guide host countries on respective paths to self reliance.

USAID TB South Africa Project Achievements

Under the USAID-funded TB South Africa Project (2016-2021), URC works to support the Government of South Africa (GoSA) National Department of Health (NDOH) to reduce the burden of TB in the country. The project works to: 

  1. reduce TB infections, 
  2. increase sustainability of effective TB response systems, and 
  3. improve care and treatment among vulnerable populations. 

The project currently supports facilities within the 14 supported districts across six provinces in South Africa, with a combined catchment population of 22.3 million people. Specifically, the project implements a cluster-based model within districts, in which facilities are grouped into clusters and mobilized to participate in cluster reviews. The project also assists with performance reviews of key indicators during these cluster reviews. Facilities with poor indicator performance or those with identified challenges are prioritized for ongoing project support. At the national level, the TB South Africa Project provides technical inputs into guidelines and policies through TB technical working groups and the TB think tank. Further, the project has seconded a manager to the national TB QA/QI initiative and leads the national initiative to find missing TB patients.

Among the total catchment population of the 14 districts, approximately 107,250 are registered as TB patients (comprised of 102,004 people living with DS-TB and 5,246 people living with DR-TB). Furthermore, it is estimated that almost 35,000 missing patients reside in the 14 supported districts and the project strategically works to locate, test and link these patients to care.

As part of the National Department of Health effort to find missing cases in South Africa, the project identified 15,603 missing cases. This represents 81% of all missing cases found in the country under this initiative, with the Global Fund funding 2,575 and provinces finding 1,171. The project continued these efforts to find an additional 3,967 cases through March 2019, for a grand total of 19,570 missing cases found.

The districts covered by TB South Africa Project have completed nearly 46 million symptom screens for TB since October 2016, identifying 1.4 million presumptive TB patients (an average of 3% presumptive positivity rate for all screens performed since October 2016) as a result. The districts supported by the TB South Africa Project have improved the percentage of health facility visitors who were screened for TB symptoms from 69% in October 2016 to 77% in June 2018. 

The facilities in the supported districts under the Project have performed 1.1 million tests for TB since the beginning of the project, representing tests for an average of 80.5% of all identified presumptive TB patients. About 89,000 of these tests were positive, resulting in 85,837 patients being initiated on treatment (on average, 96% of presumptive patients who tested positive).

Notably, TB South Africa Project’s implementation of the Finding patients Actively, Separating safely and Treating effectively (FAST) approach has identified DR-TB patients who would have been missed in a facility otherwise, therefore directly reducing the possibility of nosocomial transmission. Since April 2017, the FAST activity alone has started 190 RR-TB patients on treatment, patients who may have been missed by existing hospital-based infection prevention and control activities. 

The FAST activity has also improved screening rates from 26% in April-June 2017 to 67% by March 2019. In the context of the National Action Plan (NAP) for Combating Multidrug-Resistant Tuberculosis Objective 2.2, the FAST activity directly helps in preventing MDR-TB transmission, especially in the hospital setting.

In order to effectively reach all potential TB patients in the project districts, the project has conceptualized and forged partnerships with private general practitioners (GPs) through public-private partnerships (PPPs). The project has strategically engaged the private GPs to expand TB disease case finding and management beyond the public sector by identifying GPs in rural areas and other high burden areas to locate, treat and cure missing TB cases, in partnership with community health workers. The partnership seeks to reach over 2,000 new TB patients and provide them with treatment and support in a people-centered approach within South Africa’s National Health Insurance (NHI) framework. As of March 2019, 27,677 people had been screened for TB through this initiative, and 135 people have been started on treatment.

From October 2018, USAID TB South Africa Project provided TA to get facilities which had been accredited as decentralized sites but were not initiating patients on DR-TB care to start initiating DR-TB treatment. A total of 20 facilities were supported and clinicians were capacitated and mentored to ensure the sites become fully functional DR-TB decentralized sites. The TA model includes: an initial meeting with facility management; in service training on DR-TB regimens including the Short Treatment Regimen; mentoring of clinicians using patients requiring DR-TB treatment initiation; follow up face to face and virtual mentoring sessions; quarterly meetings with decentralized sites; enrolling the facility on the EDR Web, training of DCs; and monitoring of initiations.  Since the support was provided, a total of 41 DR-TB patients have been initiated on DR-TB sites in 18 of the 20 supported sites. 

As well, the project continues to leverage data sources in innovative ways to better understand TB hotspots in the community. Through interventions like ConnecTB and Rif alerts, the project can understand in a visual way where new cases are concentrated and where prevention and testing efforts should be focused. These interventions also work to effectively initiate patients on treatment, reduce initial loss to follow up and retain patients in care throughout their treatment.

Additionally, the USAID TB South Africa Project has produced hot-spot maps to illustrate areas of high TB transmission in eThekwini, as shown left. In plotting incident TB cases on a map, the project is able to share new and timely details with government and community stakeholders to mitigate TB transmission at the local level.

Since project activities began in 2016, the project has contributed towards tangible reductions in the South African national TB incidence. The TB incidence, as reported by the WHO Global TB report, has declined from 854 cases per 100,000 population (estimate d total of 454,000 cases) in 2015 to 781 cases per 100,000 population (estimated total of 438,000 cases) in 2016. The national TB incidence in 2017 further improved to 567 cases per 100,000 population (estimated total of 322,000 cases) compared to the two previous years as outlined in the WHO Global TB Report, 2018.

USAID TB South Africa Project Small Grants Program Achievements

South Africa is making significant progress on their journey to self-reliance.  Based on USAID journey to self-reliance, the country scored high (0.97 out of 1) on both commitment and capacity metrices for engaging local groups in development efforts. The project has issued 75 grants to 46 local non-governmental organizations (some organizations have been issued continuation grants after the first period of performance) totaling $4.3 million USD as of September 2018. 

Since the inception of the small grants program in 2017, grantee outreach activities have a combined attendance of nearly 230,000, and nearly 215,000 symptom screens for TB have been performed under the project. The small grants component has facilitated over 20,302 tests for TB (73% of those presumptive for TB after screening) through outreach programs, identifying an additional 2,055 people in the community as sputum positive for TB through door-to-door outreach and contact screening. Ninety-seven percent of those testing sputum positive for TB – nearly 2,000 people – were started on treatment by outreach activities alone. Through the special NDOH initiative to find missing cases through November 2018, the small grants component found an additional 3,316 missing cases, bringing the total contribution of the grants component to 5,371 cases found.

Further, to ensure sustainability and compatibility with existing government-offered community-based services, the project engages ward-based outreach teams (WBOTs) to integrate government-sponsored home visits with TB South Africa Project innovations like ConnecTB. WBOTs have reached over 4,000 people and through screening and testing activities have started 72 additional people on TB treatment. 

The USAID TB South Africa Project excels in MDR-TB care, especially through the NGO Model which is implemented through the small grants component. The NGO Model is a comprehensive patient engagement model which keeps patients more closely engaged in the health system through daily community care worker visits for DOT administration, side-effect monitoring, psychosocial support and household contact management. 

Overall, the small grants program has directly supported 3,154 drug susceptible TB (DS-TB) patients to TB cure through provision of Directly Observed Treatment (DOT). The DOT program has supported an additional 1,627 DS-TB patients to treatment completion, yielding a total 4,781 people who have been cured or who have completed treatment through direct, community-based NGO support, which accounts for about 2.5% of all DS-TB patients who completed treatment in South Africa in 2016.

Moving forward, the project will develop a risk-stratification model for supported patients to ensure more frequent monitoring of patients who are at highest risk for being lost to follow up, and less frequent interaction for lower-risk patients.