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USAID Tuberculosis South Africa Project Brief

USAID Tuberculosis South Africa Project Brief
Publication date: 
Jul 2019

Overview

Tuberculosis (TB) remains a major global health concern. South Africa is among thirty high TB burden coun-tries that together contribute 87 per cent of the world’s TB burden. The disease also stands as the leading cause of death in the country, particularly for men. TB accounted for the leading cause of death from a single infectious agent worldwide in 2017. The World Health Organization (WHO) estimated the national TB incidence to be 567/100,000 population in 2017. In the same year South Africa notified 227,224 cases and achieved a case detection rate of 71 per cent. To improve patient retention rates for patients with chronically managed conditions, including TB and TB/HIV co-infected patients, the Government of South Africa launched the National Adherence Guidelines and Standard Operating Procedures for TB Management.

High mortality rates of people with TB in South Africa are caused by, among others, late diagnosis, low adherence to TB treatment, and co-infection with HIV, which further weakens and compromises TB patients’ immune systems. The country has, however, made significant progress in increasing TB case detection rates (achieving 71 per cent, relative to the 70 per cent global target), improving treatment success rates for all TB patients (82 per cent), reducing loss to follow-up rates (down to 6.9 per cent), and expanding access to improved TB diagnostics. However, TB still remains a significant national public health concern.

Why are we here?

South Africa articulated a 20-year vision to achieve zero new TB infections and zero preventable deaths associated with TB. This vision is mirrored in the post-2015 WHO End TB Strategy, which sets similarly ambitious targets for ending the global TB epidemic by 2035. 

To achieve these targets, South Africa requires renewed commitment to repackaging combination high-impact interventions to improve patient outcomes and expand access to quality TB services for high-risk and key populations. 

Who are we?

The United States Agency for International Development (USAID) Tuberculosis South Africa Project is a five-year project (2016-2021) with the mandate to provide technical support to South Africa’s TB Program at national, provincial and district levels. Initiated in March 2016, we implement the USAID Tuberculosis South Africa Project in partnership with the Government of South Africa, through the South African National Department of Health (NDoH). 

We currently implement initiatives in 14 districts in six provinces. The project builds on the accomplishments of the USAID-funded TB Program South Africa (2009-2014) and the TB CARE II South Africa Project (2014-2015). 
We work at national, provincial, and district levels (in specific supported districts). 

What do we do?

We directly support goals set in the South Africa National Strategic Plan for HIV/AIDS, Sexually Transmitted Infections and TB (2017-2022).  We work to reduce TB infections, increase the sustainability of effective TB response systems and improve the care and treatment of vulnerable populations.  We also aim to improve TB prevention, diagnosis and management, and the care of persons with TB, TB/HIV and multi drug-resistant TB (MDR-TB). 

What do we aim to achieve? 

Through effective collaboration and partnership with the Government of South Africa and relevant public and private stakeholders, USAID Tuberculosis South Africa Project objectives were developed and are implemented with the aims of achieving the targets in the box on the right by 2020.

USAID Tuberculosis South Africa Project activities are implemented through the work of strategic teams and components as explained in the sections below:

Clinical and Diagnostics 

The backbone of the USAID Tuberculosis South Africa Project is the Clinical and Diagnostics team, which is primarily tasked with enhancing and sustaining the provision of quality TB services in South African health facilities.  As part of its capacity strengthening mandate, the project works with regional training centres (RTCs) nationally and provincially (i.e. in Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo, Mpumalanga and Western Cape provinces) to promote the Quality Improvement (QI) tools through skills development trainings. In addition, the team currently supports health facilities to develop QI plans and implement them to support the provision of services to patients. It also strengthens the basic TB management capacities of health workers using a low-dose high-frequency transformational skills development and retention approach.  

The foundation for infection control and transmission prevention is early and rapid diagnosis of infectious cases and proper management of TB patients to render them non-infectious. The project promotes an intensified case-finding in health facilities through implementation of the FAST Approach (Finding TB Actively, Separating safely and Treating effectively). Launched in Nelson Mandela Bay Metro, Eastern Cape Province in March 2017, the approach is designed to improve TB testing of visitors to health facilities and healthcare workers themselves.  Currently, FAST is being implemented in 67 facilities and has to date identified an additional 1,377 cases that the regular approach would have missed.

Strategic Communications

Despite the high prevalence of TB infections in South Africa, the extent of the TB epidemic and risk of TB infection have a low public profile. The Strategic Communications team aims to contribute to achieving reductions in new TB infections and increasing treatment uptake and adherence. This is primarily done through raising awareness about TB to increase demand for relevant TB services. The team employs several strategies, among them community dialogues, community awareness campaigns, material development and dissemination, as well as social and mass (television, radio, print) media to share information about TB widely. Strategic Communications is also mandated to raise the project’s visibility through developing periodic newsletters and project briefs. 

The team also works to build the capacities of healthcare providers to communicate with clients with TB better and mobilises target groups to act to protect their health.  A key strategy towards this end is training stakeholders on the use of interpersonal communication and counselling in the management of TB.

Small Grants, Key Populations, Public-Private Partnership

Using the Network Model, the Small Grants team works with community based non-governmental organisations (NGOs) to support patients on TB treatment to adhere to and complete their regimens. The team awards small grants – using a performance-based model – to local South African NGOs so they can implement context-specific and innovative community-based interventions for the benefit of patients. 

The NGOs also:

  • provide patient-centered services, including targeted TB screening, active case-finding, TB patient contact management and household environmental assessments, and 
  • increase demand for TB services through sharing information during community awareness campaigns, door-to-door visits, active case-finding initiatives and daily treatment adherence support.  

Since August 2016, the NGOs have conducted door-to-door and community awareness campaigns, and also facilitated community dialogues that resulted in 864 people being diagnosed with TB and 843 (98 per cent) linked to care.  Additionally, during the same time period, contact management was done for 11,774 index patients, resulting in 822 people being diagnosed and 805 (98 per cent) linked to care.  This means that 1,686 TB patients were diagnosed with TB and 1,648 (98 per cent) linked to care as a result of the support provided by the NGOs.

Crucially, the efforts of the team ensure that registered TB clients in supported districts where NGOs are contracted benefit from personalised patient-centred care and treatment support provided by community caregivers.  NGOs are linked to Ward-Based Outreach Teams (WBOTs) and facilitate the activities of injection teams for DR-TB patients from decentralised sites.  A proportion of drug-susceptible TB (DS-TB) and drug-resistant TB (DR-TB) patients are managed through the ConnecTB mobile health (mHealth) application. 

To date 1,831 DR-TB patients have been linked to the ConnecTB platform at various levels of DR-TB treatment. A further 2,773 DS-TB patients have recently been enrolled on the platform and their monitoring is ongoing. The treatment outcome rates are much higher for NGO-supported patients.  

The project’s Key Populations and Public-Private Partnerships component aims to develop and introduce targeted and nuanced interventions aimed at increasing integrated TB service delivery that benefits those who need it the most. The team works to increase TB diagnosis and treatment among key populations. Key populations are groups who, for a variety of reasons, are at higher risk of acquiring TB and experiencing poor treatment outcomes.  They include healthcare workers, people living with HIV, farm workers, migrants, men in general, pregnant women, and children.

The project also focuses on building and maintaining public-private partnerships with, among others, PEPFAR district support partners (DSPs), Department of Transport, Department of Agriculture, Department of Basic Education, Global Fund, BroadReach Healthcare and Sundays River Valley Citrus Growers Association. Through these and other collaborations, TB screening services are provided to inhabitants of mining, peri-mining and farming communities, and individuals linked to transport companies, correctional and healthcare services, strategic government departments, and educational institutions in various capacities.

Monitoring, Evaluation and Learning 

The Monitoring, Evaluation and Learning team tracks project performance against key indicators and evaluates the success of interventions to inform programming decisions going forward.  This work extends to monitoring the performance, challenges and successes of the health facilities supported by the project illustrated in the map below. 

The team spearheads project innovations, among them the use of ConnecTB, an mHealth application for TB patient contact management.  They also conduct geo-mapping of TB patient locations in high TB burden areas as the first step to putting them on treatment and retaining them in care.  ConnecTB is crucial to the project’s intensified and targeted TB case identification and individualised patient support provision.

The team further  coordinates project knowledge management system development and knowledge sharing activities, primarily through the documentation of success stories, project initiative write-ups, and the development and dissemination of photo essays.

Key Achievements in Quarter 3, Financial Year 2018 (April-June 2018)

The project continues to make strides in supporting TB services in the target 14 districts, with the results showing a 20 per cent increase in the primary health facility head count from the first quarter through the second quarter.

  • The proportion screened increased from 67 to 83 per cent during the same period.  Although there was just a per cent increase in the number tested, the number initiated on treatment increased by 27 per cent. The proportion of clients initiated on treatment consistently exceeded the 90 per cent national target. Furthermore, the number of clients who died or were initially lost to follow up declined by six and forty per cent respectively.
  • The project continued to maximize the use of community radio stations to educate and create awareness about TB in various districts.  The project also created continuous visibility using its social media platforms, Twitter and Facebook. Over 400 healthcare workers were trained on interpersonal communications and counselling (IPC/C) aimed at improving TB patient counselling and treatment retention. In addition, the project participated in the 5th South Africa TB Conference; hosting five satellite sessions/roundtables/symposia on the following topics: pediatric TB management, TB infection prevention and control, finding missing TB cases through prioritising key and hard-to-reach populations, the role of the private sector in TB management, and best practices in implementing mHealth innovations in limited resource settings. Further, 10 presentations (five oral and five poster presentations) were successfully delivered and shared with the wider TB and scientific communites.
  • To strengthen service delivery capacity at all levels, the project continues to build the capacities of healthcare providers to deliver evidence-based care as a crucial component of improving TB outcomes. A total of 698 managers, including HIV, AIDS, STI and TB (HAST) managers, primary healthcare (PHC) supervisors and local area managers at various levels were capacitated through review workshops.
  • In the recent past, the Government of South Africa estimated that approximately 160,000 persons infected with TB in South Africa never found their way into treatment programmes.  The project is working closely with the government and other stakeholders to implement innovative strategies to find 15,200 of the government’s target to find 40,000 missing TB patients, link and retain them in care by end of September 2018. Given the project’s effectiveness in finding missing TB patients, contact management, FAST and infection prevention and control (IPC) interventions, targeted door-to-door campaigns, improved diagnostics, district data cleaning, and targeted interventions among key populations were scaled-up significantly during the quarter.  Within two months of interventions 1,906 missing patients were identified, equivalent to 17 per cent of the anticipated target.
  • The project continues to support the government’s multi-sectoral approach to strengthen systems of care and establish partnerships, particularly for the benefit of key populations. 
  • The project implemented several QI innovative strategies focusing on rapid and targeted patient identification, use of new diagnostic assays in health facilities and strengthened operational research to improve the evidence base that will facilitate the closure of gaps along the TB Care Cascade. The QI initiatives have been introduced in all 14 supported districts, representing a health system shift in ensuring project implementation is within the existing health systems to sustain impactful innovations.  To date, the project has oriented managers from 13 of the 14 supported districts on QI and implementation is in progress in these districts.
  • The project supported NDOH to roll-out the DR-TB service package as part of global efforts to improve DR-TB patient management.  Within six months of implementation, 225 patients had been recruited into the study; all patients evaluated in the research received the package for at least six months, and 14 completed treatment.
  • To accelerate achievement of project targets, the project continued to expand the use of innovative tools, including mHealth platforms to further improve data-based planning and management. Efforts focused on identifying high TB burden areas across the project’s supported districts through geo-mapping and targeted interventions. The NGO Network Model remains a key pillar, as is engagement of the Ward-Based Outreach Teams and linking community-based NGOs to local health facilities to improve community-based TB management systems.
  • The monitoring and evaluation framework of the project is directly integrated into and aligned with the national M&E systems ensuring that project activities contribute to national targets. During Quarter 3 the project continued to support the NDOH in its endeavor to harmonise and standardise the TB recording and reporting systems including the Electronic TB Register (ETR.Net), Electronic Drug Resistance Register (EDR.Net), District Health Information System (DHIS) and the new electronic Tier system – The HIV and TB Integrated System (THIS).