REPUBLIC OF KENYA

MINISTRY OF HEALTH

© NTLD-Program 2014

All rights reserved.

TABLE OF CONTENTS

Foreword ............................................................................................................................................................... iAcknowledgements ............................................................................................................................................. iiAcronyms .............................................................................................................................................................. iiiExecutive Summary ............................................................................................................................................. viVision and Targets ................................................................................................................................................ vii

CHAPTER 1: Rationale for and Methodology of NSP Development .................................................................... 11.1. Rationale for 3-Year Plan .................................................................................................................... 11.2. Methodology ......................................................................................................................................... 1

CHAPTER 2: Background ...................................................................................................................................... 22.1. Country Profile ...................................................................................................................................... 2

2.1.1. Geography and Demographics ............................................................................................ 32.1.2. Political Structure and Policy Context ............................................................................... 32.1.3. Economic Development Agenda ........................................................................................ 3

2.2. Health Profile ......................................................................................................................................... 32.2.1. Health Status of the Population ........................................................................................... 32.2.2. Health Sector Strategy and Health Policy ........................................................................... 52.2.3. Health Financing ..................................................................................................................... 52.2.4 HIV/AIDS Policy and Financing Context ............................................................................... 6

.2.3. Epidemiology of TB, Leprosy and Lung Diseases ................................................................................. 7 2.3.1. Tuberculosis ............................................................................................................................. 7

2.3.2. HIV/AIDS .................................................................................................................................. 92.3.3. Socio- economic Burden of TB ................................................................................................. 92.3.4. Progress and Trends in Control of TB and Leprosy .............................................................. 102.3.5. Summary Findings of the Mid-Term Review 2014 ............................................................... 11

CHAPTER 3: Operational structure of the NTLD Program .......................................................................................... 15 3.1. Roles and Responsibilities ....................................................................................................... 15 3.2. Intra- and Inter-Ministry Partnerships ..................................................................................... 16

CHAPTER 4: 2015-2017 National Strategic Plan .................................................................................................... 17 4.1. Goals and Objectives of the NSP .............................................................................................. 17 4.2. Impact and Outcome Targets .................................................................................................... 17 4.3. HSSP Outcome 1: Eliminate Communicable Diseases ............................................................ 19

4.3.1. Strategy 1: Devolve implementation of activities and budgets ............................ 19 4.3.2. Strategy 2: Identify and treat all cases (find the missing cases) ............................ 21

4.3.2.1. Core DOTS .................................................................................................... 21 4.3.2.2. Programmatic Management of Drug-Resistant TB .................................. 38 4.3.2.3. Pediatric TB ................................................................................................... 46 4.3.2.4. Leprosy .......................................................................................................... 56

4.3.3. Strategy 3: Engage all care providers (PPM) ............................................................. 63 4.3.4. Strategy 4: Promote and strengthen community engagement ............................... 69 4.3.5. Strategy 5: Enhance the multi-sectoral response to TB/HIV ................................... 77 4.3.6. Strategy 6: Accelerate appropriate diagnosis ........................................................... 87 4.3.7. Strategy 7: Ensure stable & quality supply of drugs, diagnostic tests & commodities 100 4.3.8. Strategy 8: Enhance evidence-based programme monitoring and implementation 106

4.3.9. Strategy 9. Create an enabling environment .......................................................................... 117 4.3.9.1. Policy .............................................................................................................................. 117 4.3.9.2. Advocacy and Communications .................................................................................. 119 4.3.9.3. Human Rights and Gender ............................................................................................ 124 4.3.9.4. Social Protection ............................................................................................................ 129

4.4. HSSP Outcome 2: Halt/Reverse Non-Communicable Diseases ............................................................... 134 4.4.1. Strategy 10: Expand the utilization of the Practical Approach to Lung Health (PAL) ................ 134

4.5. HSSP Outcome 3: Minimize Risk Factor Exposure ..................................................................................... 140 4.5.1. Strategy 11: Prevent transmission and disease: IPC, IPT and contact tracing ............................. 140

CHAPTER 5: Resource Implications of the NSP .......................................................................................................................... 144

ANNEXESAnnex 1: NSP Writing Team .......................................................................................................................................................... 149

Annex 2: Stakeholder Meeting Participants ................................................................................................................................ 150

TABLE OF CONTENTS

FOREWORD

The Kenya National Strategic Plan on Tuberculosis, Leprosy and Lung Diseases 2015 – 2018, marks a milestone in our nation’s response to these diseases.

This national strategic plan has been birthed through a robust country dialogue, which brought together various stakeholders, including the national and county governments, bilateral and multilateral development partners, non-governmental organizations, civil society organizations, tertiary medical training institutions and key affected population representatives, among others.

The strategic plan is based on epidemiological analysis of the burden of these diseases and information gleaned from the program review. The plan is aligned to the Kenya Health Sector Strategic and Investment Plan 2013 - 2017 and the global post – 2015 plan. It promotes strategic interventions unique for each county, and which have the greatest impact for case notification, childhood tuberculosis, drug resistant tuberculosis, leprosy and lung diseases. For the first time, priority interventions related to key affected populations, gender and human rights are covered.

On the same note, we must endeavor to put together our synergistic efforts and pull in the same direction so as to deliver on Chapter IV Article 43 I (a) of the Kenyan Constitution that envisages access to the highest attainable standard of health to our people.

Dr Nicholas Muraguri, Director of Medical ServicesMinistry of Health, Government of Kenya

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The 2015-2018 National Strategic Plan (NSP) for the Control of Tuberculosis, Leprosy and Lung Diseases represents the leadership and commitment of the Ministry of Health, Kenya. The team wishes to acknowledge the leadership of the National Tuberculosis, Leprosy and Lung Diseases Program (NTLD Program). Additionally, the writing team benefitted from the extensive knowledge and expertise of Ministry of Health staff and partners at all levels of the health system.

The planning secretariat included Dr Joseph Sitienei, Head, Division of Communicable Disease Prevention and Control, MoH; Dr Jackson Kioko, Head, NTLD Program; Dr Enos Masini (NTLD Program); Dr Samuel Kinyanjui, Chief of Party, Centre for Health Solutions (CHS); Dr Brenda Mungai, Deputy Chief of Party, CHS; Dr Kadondi Kasera, CHS; Dr Maurice Maina, U.S. Agency for International Development (USAID); Dr Herman Weyenga, U.S. Centers for Disease Control and Prevention (CDC); Dr Joel Kang’angi, World Health Organization (WHO)/Kenya; and Dr Jane Ong’ang’o, Kenya Medical Research Institute (KEMRI).

The full list of the writing team is included as Annex 1.

The staff of various units and departments within the Ministry of Health, county and sub-county officials, as well as bilateral and multilateral donors and agencies, and non-governmental and civil society organizations made, valuable contributions.

ACKNOWLEDGEMENTS

Dr Jackson Kioko, Head, Department of Preventive and Promotive HealthMinistry of Health, Government of Kenya

We also wish to make special mention of the following long-term partners of the NTLD Program: National HIV/AIDS and STI Control Programme (NASCOP), WHO, USAID, Centre for Health Solutions - Kenya (CHS), Amref Health Africa, Management Sciences for Health (MSH), Programme for Appropriate Technologies in Health (PATH), Kenya Association for the Prevention of Tuberculosis and Lung Disease (KAPTLD), Kenyatta National Hospital (KNH), Kenya AIDS NGOs Consortium (KANCO), KEMRI, CDC, International Organization for Migration (IOM), Japanese Agency for Cooperation (JICA), Tuberculosis Advocacy Consortium (TAC), and the World Bank.

This multi-sectoral and partnership approach ensured that the NSP represents the collective best thinking of a broad range of stakeholders. A full list is available as Annex 2.

The writing team wishes to thank Macalester College in the United States, and Professor Christy Hanson for her leadership in the NSP development. The Ministry also wishes to thank students and staff, including Omar Mansour, Riccardo Maddalozzo, Asad Zaidi, Chloe Schumaker and Karla Nagy for their support in conducting background literature reviews, data analysis, geographic mapping, and document formatting.

The Ministry of Health is grateful for generous financial support from USAID, through CHS and the Global Fund, which enabled the numerous stakeholder meetings and workshops for the writing team.

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ACSM Advocacy, Communication, and Social MobilizationADR Adverse Drug ReactionAFB Acid-Fast BacilliAFRO African Regional Office (of the World Health Organization)AIDS Acquired Immune Deficiency SyndromeAMREF African Medical and Research FoundationARI Acute Respiratory Infection ART Anti-Retroviral TherapyBOLD Burden of Lung Disease BSC Bio-Safety CabinetBSR Blinded Slide RecheckingC+ Culture PositiveC- Culture NegativeCAP Community Acquired PneumoniacART Combined Anti-Retroviral TherapyCBO Community-Based OrganizationCBHIS Community-Based Health Information SystemCCT Conditional Cash TransferCDC United States Centers for Disease ControlCDR Case Detection RateCHEW Community Health Extension WorkersCHU Community Health Program CHS Centre for Health Solutions - KenyaCHSU Community Health Service UnitsCME Continuing Medical EducationCNR Case Notification RateCoEs Centers of ExcellenceCOPD Chronically Obstructive Pulmonary DiseaseCPT Cotrimoxazole Preventive TherapyCR Cure RateCQIs Continuous Quality ImprovementsCSO Civil Society OrganizationCSR Corporate Social ResponsibilityCTBC Community Tuberculosis Care CTLC County TB and Leprosy CoordinatorCU Central ProgramCXR Chest X RayDALY Disability-Adjusted Life YearDCDPC Division of Communicable Disease Prevention and ControlDOT Directly Observed TreatmentDOTS Directly Observed Treatment, Short-CourseDQA Data Quality Assessment DRS Drug Resistance SurveillanceDR-TB Drug Resistant TuberculosisDSSM Direct Sputum Smear MicroscopyDST Drug Susceptibility TestingDTLC District TB Lab CoordinatorDMLT District Medical Laboratory TechnologistEQA External Quality AssessmentETR Electronic TB RegistryFBC Full Blood CountFBO Faith-Based Organizations

ACRONYMSiii

FIND Foundation for Innovative New DiagnosticsFDC Fixed Dose CombinationFM Fluorescence MicroscopyGDF Global Drug FacilityGF Global Fund to Fight AIDS, Tuberculosis, and MalariaGLC Green Light CommitteeGoK Government of KenyaH IsoniazidHC Health CenterHCP Health Care ProviderHCW Health Care WorkersHISP Health Insurance Subsidy ProgrammeHIV Human Immunodeficiency VirusHMIS Health Management Information SystemHSSF Health Sector Services FundHTC HIV Testing And Counseling IC Infection ControlICC Inter-Agency Coordinating CommitteeICF Intensified Case FindingICT Information, Communication and Technology IEC Information, Education, and CommunicationIOM International Organization for MigrationINH IsoniazidIPC Infection Prevention and Control IPT Isoniazid Preventive TherapyISAAC International Studies of Asthma and Allergic Disease in Childhood ISTC International Standards on TB CareIT Information TechnologyJICA Japanese Agency for Cooperation KAD Kenya Association of DermatologistsKDVO Kenya Dermato-Venereology OfficerKAIS Kenya AIDS Indicator SurveyKANCO Kenya AIDS NGOs Consortium KAP Knowledge, Attitude And PracticesKAPTLD Kenyan Association for the Prevention of Tuberculosis and Lung DiseasesKCOA Kenya Clinical Officers Association KEMRI Kenyan Medical Research InstituteKEMSA Kenya Medical Supplies AgencyKHPF Kenya Health Policy FrameworkKMA Kenya Medical Association KNCV Koninklijke Nederlandse Chemische Vereniging (Royal Netherlands Tuberculosis Foundation)KPA Kenya Pediatric AssociationLED Light-Emitting Diode Microscopes LFT Liver Function TestLMIS Laboratory Management Information SystemM&E Monitoring and EvaluationMB Multi-Bacillary LeprosyMC Microscopy CenterMCH Maternal and Child HealthMDG Millennium Development GoalMDR-TB Multi-drug Resistant TuberculosisMNCH Maternal, New Born and Child HealthMOH Ministry of HealthMOP Manual Of ProceduresMOPC Medical Outpatient ClinicMSF Medecins Sans FrontieresMSH Management Sciences For HealthMTB Mycobacterium TuberculosisMTEF Medium Term Expenditure FrameworkMTR Mid-Term ReviewNACC National AIDS Control CouncilNASCOP National AIDS and Sexually Transmitted Infections Control ProgrammeNCC National Coordinating Committee

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NGO Non-Governmental OrganizationNHA National Health AccountsNHSSP National Health Sector Strategic PlanNHIF National Hospital Insurance FundNSR No Smear ResultNTLD Program National Leprosy, Tuberculosis and Lung Disease ProgramNTRL National TB Reference LaboratoryNPS/NTPS National TB Prevalence SurveyOOP Out-Of-PocketOR Operational Research PAL Practical Approach To Lung HealthPATH Program for Appropriate Technologies in HealthPBG Performance-Based GrantPCR Polymerase Chain Reaction PHC Primary Health Care PHO Physician Hospital OrganizationPLHIV People Living With HIVPMDT Programmatic Management of Drug-resistant TuberculosisPMTCT Prevention of Mother-To-Child Transmission of HIVPNK Pharmaceutical Society of KenyaPP Private PractitionersPPB Pharmacy and Poisons Board PPE Personal Preventive EquipmentPPM Public-Private Mix DOTSPSM Procurement and Supply Management PPR Policy Planning and Research PT Proficiency Testing QA Quality AssuranceQAS Quality Assurance SystemQC Quality ControlQMRL Queensland Mycobacterium Reference LaboratoryQMS Quality Management System R RifampicinRCC Regional Coordinating CommitteeS+ Smear PositiveS- Smear NegativeSCTLC Sub-County TB and Leprosy Coordinator SHA System Of Health Account SOP Standard Operating ProceduresSRL Supranational Reference LaboratorySTI Sexually Transmitted InfectionsTA Technical AssistanceTAG Tuberculosis Action GroupTAT Turn-Around TimeTB TuberculosisTB/HIV TB Disease and HIV InfectionTIBU Treatment Information from Basic ProgramTOT Training of Trainers TSH Thyroid Stimulating HormoneTSR Treatment Success RateTST Tuberculin Skin TestTWG Technical Working GroupUEC Urea, Electrolytes, CreatinineUSAID United States Agency for International DevelopmentWHO World Health OrganizationZN Ziehl-Neelsen

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The Government of Kenya has a vision to reduce the burden of lung disease in Kenya and render Kenya free of TB and leprosy. Towards this aim, the National Tuberculosis, Leprosy and Lung Disease Program (NTLD Program) has been implementing activities within the framework of a five-year (2011-2015) national strategy. TB is a major cause of morbidity, with nearly 90,000 cases notified in 2013. It is the 4th leading cause of death in the country.

Kenya is globally recognized as a pathfinder for TB and leprosy control. Within Africa, Kenya was the first country to achieve World Health Organization (WHO) targets for case detection and treatment success of new smear-positive pulmonary TB cases. Treatment success continues to be a hallmark of the NTLD Program, with rates among new smear-positive cases averaging over 88% among HIV-negative patients, 82% among PLHIV, and approximately 68% among those being treated for MDR-TB. The country has been a leader in rolling out TB/HIV collaborative activities. In 2013, over 93% of patients with TB disease were tested for HIV. About 98% of those with TB and HIV co-infection (TB/HIV) received cotrimoxazole preventive therapy (CPT), and 83% started on anti-retroviral therapy (ART).

In line with the constitution, devolution of government functions and resources to 47 newly created counties is swiftly changing the mode of operations in the health sector, including the management of TB, leprosy and lung disease. The health sector, previously characterized by central-level planning and supply-side financing, is shifting to devolved planning and demand-side financing modalities, including national health insurance, conditional and performance-based grants, and equity-enhancing allocations of national resources.

Devolution presents opportunities for local prioritization and adaptation of TB and leprosy control activities that are targeted and patient-centered. Translating the cascade model of technical excellence and assistance into the new structure is ongoing and will require additional human resources and new skill sets, given the expanded number of administrative units and new requirements for planning capacity at county level. The NSP describes how the gains of the past five years will be sustained under this new system of governance.

With an already declining rate of TB case notification, it is time to build on the Program’s solid foundation with a stronger focus on the prevention of transmission. The Health Sector Policy calls for a 62% decline in deaths due to communicable diseases by 2018. To build towards achieving this goal, the NTLD Program will: a) implement quality enhancements; b) re-align the program’s operations to the new governance structure, ensuring unified commitment from both national and county levels; and c) rapidly introduce/expand prevention efforts, including reducing diagnostic delays to diminish transmission.

This four-year National Strategic Plan (NSP) for TB, leprosy and lung disease represents a transition to: a) program implementation through the newly established 47 counties; and b) intentional acceleration of declining incidence. The NSP is based on robust evidence generated by the national case-based electronic data system, Tuberculosis Information from Basic Units (TIBU) as well as results of small-scale pilot projects and operational research. The NSP intentionally capitalizes on well-performing counties as mentors and training hubs for others, while also scaling up high impact pilot projects. It describes a county-tailored approach to the prioritization of technical assistance and programmatic enhancements addressing particular challenges of each county and sub-population.

EXECUTIVE SUMMARYvi

Figure 1: Strategic Plan Vision, Goals, Impact Targets and Strategic Objectives

KENYA NATIONAL STRATEGIC PLAN FOR TB, LEPROSY AND LUNG HEALTH 2015-2018

   

Vision To reduce the burden of lung disease in Kenya and render Kenya free of Tuberculosis and Leprosy

Goal To accelerate the reduction of TB, Leprosy and lung disease burden through provision of people-centered, universally accessible, acceptable and affordable quality services in Kenya

Impact Targets

By 2018: 1. Reduce the incidence of TB by 5%, compared to 2014

1.1 Reduce the prevalence of MDR-TB among new patients by 15% 1.2 Reduce the incidence of TB among PLHIV by 60%

2. Reduce mortality due to TB by 3% 3. Reduce the proportion of affected families who face catastrophic costs due to TB,

Leprosy and lung diseases 4. Reduce by 50%, the proportion of cases with grade 2 disability due to leprosy 5. Reduce mortality due to chronic lung diseases e.g. COPD, asthma

Strategic Objectives

1. Sustain the gains in the context of a newly devolved health system

2. Intensify efforts to find “missing” cases

3. Reduce transmission

4. Prevent active disease and morbidity

5. Enhance the quality of care for chronic lung diseases

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CHAPTER 1

RATIONALE AND METHODOLOGY OF NSP DEVELOPMENT1.1. Rationale for Planning Period

The current Health Sector Strategic Plan covers 2013-2017. To align this NSP with the national planning cycles, it will cover four years, running from 2015 to mid 2018. Subsequent NSPs will be aligned to the country’s medium term plans.

1.2. MethodologyThe development of the NSP started in earnest with the NTLD Program carrying out an epidemiological assessment and impact evaluation with technical assistance from WHO Kenya and CDC. The Epidemiological Assessment and Impact Evaluation Report 2014, served as a critical background document for the mid-term review (MTR) of the 2011 - 2015 NSP, which took place in March 2014. The findings from both the assessment and review were shared widely.

As part of the country’s dialogue spirit, two stakeholder meetings were convened under the leadership of the NTLD Program that brought together the national government, county governments, donors, technical partners, civil society organizations, non – governmental organizations, medical institutions of higher learning, medical research institutes, key populations, private health providers and medical insurance companies.

To support the writing of the document, a drafting team was drawn from the participants of the stakeholder meetings. This drafting team was diverse in both composition and sector representation. The stakeholder meetings were held interchangeably with drafting retreats. The first stakeholder meeting fed into the first drafting retreat that led to a sub–zero NSP draft. The second stakeholder meeting was held to share and further develop the sub –zero NSP draft. Subsequently, the final drafting retreat was held to incorporate the feedback from the second stakeholder meeting.

This entire process ultimately gave birth to the country’s prioritized needs with county–specific interventions. Consensus was reached on the goal, the impact and outcome targets, and the strategic objectives for the 2015 – 2018 NSP. A costing plan, operational plan, and monitoring and evaluation plan were developed at the conclusion of the drafting. The final draft was shared electronically with all the stakeholders and feedback incorporated by the NSP development secretariat.

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CHAPTER 2

BACKGROUND

2.1. Country Profile

2.1.1. Geography and Demographics

Kenya is located in the African Great Lakes region, in the Eastern part of the continent. It has a total surface area of 581,309 km2 (or 224,445 sq mi) and it borders Tanzania to the south, Uganda to the west, South Sudan to the northwest, Ethiopia to the north and Somalia to the northeast.

According to July 2013 estimates, Kenya has a total population of 44 million1, making it the seventh most populated country in Africa. The population increased by 14% between 2009 and 2013, based on the most recent census. The total fertility rate in 2012 was 4.46. This was a decline from 4.54 in 2011, but an increase from 3.66 children per woman of childbearing age reported in 2000. Kenya’s population is thus rapidly growing. World Bank projections predict that it could increase further to 85 million by 2050. Reflecting this rapid surge, Kenya’s population is young, with UN statistics reporting that 42.2% of the population is below the age of 15. According to the World Health Organization (WHO), life expectancy is 58.1 for men and 61.4 for women, making an average life expectancy at birth of 59.7 years.

Kenya’s population is mostly rural, with only 24% of Kenyans living in urban settlements2. The main urban area being the capital city of Nairobi, which hosts over three million people. The country has experienced sustained economic growth, with GDP per capita increasing from US$404 in 2000 to US$943 in 2012. Nonetheless, Kenya continues to have chronically high levels of poverty. The World Bank poverty estimates range between 34 to 42% indicating that a huge part of the Kenyan population was living below the poverty line in 2013. Estimates suggest that 72.2% of adults are literate, but there are significant inequities and age distribution3. Encouragingly, literacy is higher (82.4%) among people aged 15-243. Kenya is a demographically and linguistically diverse country with 42 different ethnic tribes and 69 languages4.

_________________________________________________________________________________________________________________________________1 CIA Factbook2 WHO3 UNESCO4 Ethnologue

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2.1.3. Economic development agenda

Kenya’s Medium Term Expenditure Framework (MTEF) 2012/2013 – 2015/2016 aims to facilitate “an effective and efficient use of Government resources”, considering that internal reviews of performance noted an ineffective management of public spending. The MTEF has three specific goals:

1. Maintain aggregate fiscal discipline by ensuring that policy changes are consistent with fiscal norms and program objectives

2. Increase efficiency in resource allocation3. Promote efficient delivery of services.

2.2. Health Profile

2.2.1. Health status of the population

The principal causes of deaths and of Disability-Adjusted Life-Years (DALYs) reported by the Kenyan Government Review of the Health Policy Framework 1994 - 2010 are listed in Table 1 below.

The main risk factors to health in Kenya include unsafe sex, suboptimal breastfeeding, alcohol and tobacco use, obesity and physical inactivity, amongst others. Such factors, particularly tobacco use and unsafe sex, are asscociated with TB/HIV co-infection and contribute to the burden of lung diseases, and are considered in this NSP.

Available evidence suggests a reduction in unsafe sexual practices, though the HIV incidence remains high in selected counties. This is attributed to steady improvements in knowledge and attitudes of communities regarding sexually transmitted infections and conditions.

Breastfeeding practices have also changed, with exclusive breastfeeding for up to five (5) months showing significant improvements.

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2.1.2. Political structure and policy context

Kenya’s Vision 2030, the country’s development blueprint, was finalized in 2007. It aims to achieve “a globally competitive and prosperous Kenya with a high quality of life by 2030.” The key role that health plays in maintaining the healthy and skilled workforce needed to drive the economy made health one of the key components of the vision’s social pillar.

To align with Vision 2030, the health sector defined priority reforms as well as flagship projects and programs, including restructuring of the sector’s leadership and governance mechanisms; improving procurement and availability of essential medicines and medical supplies; modernizing health information systems; accelerating health facility infrastructure development to improve access; development of human resource for health; strengthening of equitable financing mechanisms; and establishment of social health insurance.

The new Constitution, adopted in 2010, replaced a governance structure of eight provinces with 47 newly created counties. Kenya adopted a bicameral legislature composed of Senate (Upper house) and The National Assembly (Lower House). The senate was re-established with the 2010 Constitution. It has 47 members elected directly by the counties with powers to represent the interests of counties, participate in law making and determine budgeting allocation and has powers of impeachment over President, Deputy President, County Governor and Deputy Governor. The National Assembly, on the other hand, has 349 members; 290 elected from constituencies, 47 women elected from the counties and 12 nominated members.

In line with the new Constitution, the devolution of government functions and resources to the 47 counties is swiftly changing the mode of operations for the health sector including the management of TB, leprosy and lung disease. The health sector, previously characterized by central-level planning and supply-side financing, is shifting to devolved planning and demand-side financing modalities including national health insurance, conditional and performance-based grants, and equity-enhancing allocations of national resources.

Cause of Death

Rank Disease % of deaths

1 HIV/AIDS 29.3

2 Conditions arising during perinatal period

9.0

3 Lower respiratory infections 8.1

4 Tuberculosis 6.3

5 Diarrheal diseases 6.0

6 Malaria 5.8

7 Cerebrovascular disease 3.3

8 Ischemic Heart Disease 2.8

9 Road traffic accidents 1.9

10 Violence 1.6

Source: Kenya Health Policy (2012-2030)

Table 1: Principal causes of deaths and of DALYs

Cause of DALYs

Rank Disease % of DALYs

1 HIV/AIDS 24.2

2 Conditions arising during perinatal period

10.7

3 Malaria 7.2

4 Lower respiratory infections 7.1

5 Diarrheal diseases 6.0

6 Tuberculosis 4.8

7 Road traffic accidents 2.0

8 Congenital anomalies 1.7

9 Violence 1.6

10 Unipolar depressive disorders 1.5

Tobacco use remains high, particularly among productive populations in urban areas and among males. Evidence shows that one in five males aged 18 – 29 years and one in two males aged 40 – 49 years are using tobacco products. Tobacco use has been associated with chronic obstructive lung disease, recurrent UTIs, malignancies, including lung cancer and increased risk of developing active TB disease.

Obesity appears to be on the rise, with an increasing population of Kenyans being overweight. It is anticipated that this will fuel an increase in diabetes, a known co-morbidity for TB. It is estimated that 25% of all persons in Kenya are overweight or obese, with the prevalence being highest among women in their mid to late 40s and in urban areas.

A 2007 Household Health Expenditures and Utilization Survey reports that more than half of outpatient visits (57%) occur in government facilities, while private and mission facilities account for 24%, and traditional healers for about 1%. Chemists are the first visit for around 15% of patients. Approximately 38% of people who did not seek care cited financial concerns/constraints as the reason. Gender was also an important determinant of outpatient services utilization, with women making for 1.3 times as many visits per capita as males (2.9 vs. 2.3).

The 2007 Survey also highlighted a major improvement in access to outpatient services, with the poor more likely to seek outpatient medical attention than their wealthier counterparts. Urban dwellers reported seeking inpatient services more than their rural counterparts (38/1,000 vs. 24/1,000). Unlike outpatient care, inpatient services were strongly correlated with wealth index, with individuals in the richest quintile twice as likely to use inpatient care compared to those in the lowest one, a trend that remained largely unchanged since 2003.

Lastly, while 75% of the richest household and 55% of the poorest had money to cover immediate inpatient services, 14% still reported having to either borrow or sell property to be able to comply with the payments, suggesting the importance of pursuing social protection programs.

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2.2.2. Health sector strategy and health policy

The Kenya Health Policy Framework (KHPF) was the basis for the health development agenda in Kenya from 1994-2012. The framework emphasized “quality health care that is acceptable, affordable and accessible to all.”

The implementation of this framework was divided into two five-year strategic plans: the National Health Sector Strategic Plan (NHSSP I, 1999-2004), and the National Health Sector Strategic Plan II (NHSSP II, 2005-2010).

The Kenya Health Policy 2012 – 2030 aims at attaining the highest possible health standards in a manner responsive to the population needs.

The policy aims to achieve this goal through supporting provision of equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans. It also aims at attaining a level and distribution of health that is commensurate with a middle-income country through attainment of specific health impact targets. The policy directions in the Kenya Health Policy are structured around Six Service Delivery outcomes and Seven System investment orientations.

Consistent with the Health Policy, the National Health Sector Strategic Plan III (NHSSP III, 2012-2017) is currently being implemented. NHSSP III has the following policy objectives that relate to the control of TB, leprosy and improvement of lung health; all of which are aligned with the realization of the Health Sector Vision:

1. Eliminate communicable conditions: This is to be achieved through reducing the burden of communicable diseases, until they are not of major public health concern.

2. Halt, and reverse the rising burden of non-communicable conditions: This is to be achieved by ensuring clear strategies for implementation to address all the identified non-communicable conditions in the country.

3. Provide essential health care: These shall be medical services that are affordable, equitable, accessible and responsive to client needs.

4. Minimize exposure to health risk factors: This aims at strengthening the health promoting interventions, which address risk factors to health, plus facilitating use of products and services that lead to healthy behavior in the population.

5. Strengthen collaboration with other sectors: This aims at adopting a ‘Health in all Policies’ approach, which ensures the Health Sector interacts with and influences design, implementation and monitoring processes in all health related sector actions. In addition, it is critical that other sectors of government and non-state actors reach populations for prevention, screening, communication, and treatment follow-up.

2.2.3. Health financing

Overall, expenditures for the health sector are estimated at US$40 having increased from US$17 per capita. This is due to increased government and donor resources, with the proportion of household expenditures reducing as a proportion of the total expenditures. The health expenditure as a proportion of the GDP and the general government expenditure stagnated during the same period.

Out of pocket spending is highest in the wealthier provinces of the country. Financial risk protection has steadily increased with an estimated 17% of the total population benefiting from the same. Evidence from the National Health Accounts 2010 demonstrated improvements in allocation efficiencies, with more services being provided using the same amounts of resources in real terms. However, resources are increasingly being directed to management functions as opposed to service delivery.

Looking at actual expenditures, limited real improvements in human resources for health and infrastructure were noted during the previous policy period. There have been limited improvements in human resource for health and infrastructure despite an increase in investment in the two areas in the 2005-2010 period. This is a reflection of the stagnation of real resources for health. Improvements in real terms are only notable in the last two (2) years of the policy period (2009 and 2010).

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_______________________________________________________________________________________________________________________________5 Taken directly from “The Kenya AIDS Epidemic – Update 2012” – National AIDS Control Council

2.2.4 HIV/AIDS policy and financing context5

Kenya’s response to HIV is guided by a strategic plan that aims to harmonize and align the HIV-related activities of diverse partners and stakeholders. Coordinated by the National AIDS Control Council (NACC), HIV response builds on the robust engagement of civil society and people living with HIV. The National AIDS and STI Control Programme (NASCOP) within the Ministry of Health, administers the bulk of HIV-related services in Kenya. The country has developed a series of performance indicators to drive progress and promote accountability in the response.

Declaring HIV a national disaster in 1999, the Government established the National AIDS Control Council (NACC) within the Office of the President to coordinate national response to the epidemic. An important step in establishing a rights-based framework for effective action on HIV occurred in September 2003, when the Government approved legislation making it illegal to engage in employment discrimination on the basis of a person’s HIV status. The law also prohibited insurers from withholding services to people living with HIV or from imposing discriminatory premiums on HIV-infected individuals.

In 2006, Kenya enacted the HIV and AIDS Prevention and Control Act. The law formally protects the rights of people living with HIV, prohibits mandatory HIV testing, and authorizes various measures to mitigate the epidemic’s impact. It also prohibits discrimination on the basis of one’s HIV status and disallows insurers from withholding services to people living with HIV. Although this law does not specifically address vulnerable populations, other laws, such as the Sexual Offence Act and the Children’s Act, provide explicit protection to women, children and young people. Formal policies and guidelines have been developed to support program planning and implementation with respect to specific aspects of HIV response. These normative frameworks aim to ensure that Kenya’s HIV response is firmly grounded in available evidence.

Financing for HIV programs in Kenya rose roughly seven-fold from 2000–2001 to 2008–2009. However, the continuing global financial and economic downturn threatens future HIV funding. The U.S. Government, the single largest source of HIV funding in Kenya, is capping its financial support for HIV programs in the country. In response to the uncertainty of future international HIV assistance, Kenya has embarked on a national effort to mobilize new sources of financing, with particular focus on increasing domestic funding for HIV. The Government of Kenya has already taken steps to increase domestic support for HIV programmes, with domestic HIV outlays nearly doubling between 2006–2007 and 2008–2009.

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2.3. Epidemiology of TB, HIV, Leprosy and Lung Diseases

2.3.1. TuberculosisFrom the TB Epidemiological and Impact Analysis Report of 2014, various trends were noted and these have been highlighted in this section.

Analysis of the trends in estimates of TB incidence (Figure 2) suggests a consistent decline in new TB cases over time. The decline in TB cases started in 2005 following the decline in TB/HIV cases, which started in 2004. Furthermore, after a peak in 2006, the TB prevalence declined and thereafter plateaued from 2009 (Figure 3). TB mortality estimates suggest an increase in TB deaths in 2011-2012 (Figure 4). However, the wide confidence intervals indicate considerable uncertainty in the estimates, suggesting the need for other more direct methods to measure prevalence and mortality.

Figure 4: Trends in TB Mortality

Data on TB prevalence and mortality are sparse. Kenya has not conducted a national TB prevalence survey in the recent past (the last TB prevalence survey was conducted in 1956), but the NTLD Program is planning to carry out a prevalence survey in 2015.

There is currently no national level vital registration system with standard ICD-10 coding in place. Less than half of deaths are recorded, and approximately 10% of deaths receive an ICD code. Results from a prevalence survey and vital registration systems would provide data on the current status of the TB burden and the effectiveness of TB control interventions.

The TB case notification showed an upward trend from 2003 to 2007, when it peaked with 116,000 cases. Thereafter, it has steadily declined, reaching an all time low of 89,000 in 2013 (Figure 5)6. This may be explained by better TB and HIV control efforts, as well as the recent introduction of the electronic case based surveillance. An inventory study would, however, be necessary to confirm this sharp decline.

Figure 5: Trends in TB Related Deaths among PLWHIV

Figure 2: Trends in TB Incidence Figure 3: Trends in TB Prevalence

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TB case notification patterns vary across reporting zones. A majority of zones experienced gradual decline in notified cases from 2007-2012 (e.g. Western, Nyanza South, Nairobi South). On the contrary, a few zones showed an increase. They included Rift Valley South and North Eastern, especially those harbouring refugee groups. Some zones like Nyanza North and Nairobi North had variable case notification reporting. These stark differences are likely evidence of data management problems.

Males had higher TB case notification rates than females among all age groups, except for children (0-15 years) and young adults (15-24 years). Adults aged 35 - 44 years had the highest CNR with the rates of TB among males being 30% greater than that of females.

The NTLD Program has continued to successfully screen about 93% of all notified TB cases for HIV. The current prevalence of HIV among notified TB cases is about 37%. The HIV prevalence among notified TB cases is also 37%7 but varies by region. Zones with higher HIV prevalence are associated with higher co-infection rates. Prisons contributed to about 1% of the notified TB cases in 2013. Surveillance for DR-TB among retreatment cases has led to increased reporting with 290 cases notified in 2013. Refugees constituted 28% of the MDR-TB cases detected in 2013.

The relative numbers of new bacteriologically confirmed (smear positive) cases and extra pulmonary TB cases have remained fairly consistent over time. From 2003 to 2012 the proportion of new cases that were bacteriologically confirmed ranged from 37.3 – 43.0%, while the proportion of new extra pulmonary cases increased gradually since 2003, but maintained a narrower range: 15.1% to 18.2%.

For the past five years, the proportion of retreatment cases has remained just below 10% of all notified TB cases. (Figure 14). Data on TB in other high-risk populations and in patients with underlying comorbidities is not readily available from TIBU.

_______________________________________________________________________________________________________________________________6 & 7 NTLD Program Annual Report 2013

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Figure 6: Trends in Notified TB Cases in Kenya (2003-2013)

2.3.2. HIV/AIDS

In 2014, the Kenya AIDS Indicator Survey was published. This section highlights some of the findings of the report.

According to the UNAIDS Global Report 2013, Kenya is ranked 4th in the world in terms of HIV prevalence, with an estimated 1,600,000 people living with HIV in the country.

Kenya’s HIV prevalence has declined from 7.2% in the general population in 2007 to 5.6% in 2014 (KAIS 2014 Report). Women have consistently been more affected by HIV than men. Currently 6.9% of women in Kenya are living with HIV (down from 8.5% in 2007) compared to 4.4% of men (down from 5.5% in 2007). Women with secondary education reported having higher infection rates (7.4%) compared to those with no primary education at all (4%). A similar pattern is observed in men with 2.4% among those with no primary education and 4.4% in those with secondary education. However, the prevalence is highest at 4.8% among men who completed primary education.

HIV is not evenly spread throughout the country, with the Eastern North (2.1%) and North Eastern (0.5%) having significantly lower prevalence compared to other parts, particularly the West.

Nyanza region reported a prevalence of 15.1%, increasing slightly from 14.9% in 2007. Nyanza was also one of the only two regions that experienced an increase, although limited, in the prevalence, together with Central region where the prevalence rose from 3.6% to 3.8%. The rest of the country has witnessed a considerable decline in HIV prevalence, especially the Coast region (from 8.1% to 4.3%) and Nairobi (from 8.8% to 4.9%).

HIV prevalence was higher among urban dwellers compared to rural dwellers, being 6.5% and 5.1% respectively. About 8% of urban females were HIV infected compared to 6.2% of rural females, and 5.1% of urban males were living with HIV compared to 3.9% or rural men.

Marital status also shaped different patterns of the disease, particularly negatively affecting widowed men and women with an infection rate of about 20% (M: 19.2% and F: 20.3%), ten times higher than among individuals who never married or cohabited (1.8%).

Among HIV infected adults, 58% were eligible for anti-retroviral therapy (ART). They had a CD4+ cell count equal to, or below 350 or in stage III or IV and with co-infections. Among those eligible, 63% reported using ART and 78% of them also reported achieving viral suppression. About 11.9% of all HIV infected persons reported having a history of TB.

2.3.3. Socioeconomic burden of TB

Tuberculosis is known to have a strong association with poverty8. Patients and households affected by TB are likely to be caught in a ‘medical poverty trap’ – a situation where treatment expenditures increase as income levels decrease.

In one study, the median total cost incurred as a result of TB infection in Kenya was KSH 22,753 (US$ 350), a figure that was roughly equivalent to a quarter of the median household income measured before the onset of the illness. Most patients must borrow money or sell assets to meet the expenses they face due to illness. Indirect costs, primarily in the form of loss or reduction of income, account for about 85% of the economic burden Kenyan individuals and households affected by TB incur, with median indirect costs amounting to an estimated KSH 19,123 (US$ 294). Significant decreases in productivity are reported as a result of TB illness. During treatment, direct costs are incurred when patients have to travel to get medication or for follow-up sputum tests. Food, accommodation, and drug administration also contribute to direct costs. Costs due to Direct Observation of Treatment (DOT) are rarely incurred as most patients receive DOT from their family members. As a result of the high prevalence of HIV/TB co-infection, many TB patients must also cover expenses brought about by their HIV+ status9.

Over half of the TB patients are malnourished to some degree at the onset of treatment, with 17% being severely malnourished and a further 22% being moderately malnourished10.

The TB control strategies outlined in this NSP take into consideration these socioeconomic determinants and aim to cushion patients from the negative impact.

_______________________________________________________________________________________________________________________________

8 WHO Addressing Poverty in TB Control Guidelines 20059 Mauch, V., Woods, N., Kirubi, B., Kipruto, H., Sitienei, J., & Klinkenberg, E. (2011). Assessing access barriers to tuberculosis care with the tool to Estimate Patients’ Costs: pilot results from two districts in Kenya. BMC Public Health, 11(1), 43.10 http://digitalcommons.calpoly.edu/cgi/viewcontent.cgi?article=1009&context=fsn_fac

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2.3.4. Progress and trends in control of TB and leprosy

Kenya is one of the 22 high burden TB countries that together account for more than 80% of the world’s TB cases. WHO estimated that there were 120,000 new cases of TB in Kenya in 2012. The estimated 9,500 (5,400-15,000) deaths due to TB make it the fourth leading cause of mortality in the country. Since 2006, a gradual decline in case notification has persisted, suggesting that incidence may be declining following years of high treatment success, currently at over 88%. Case detection has been enhanced through community engagement, inclusion of the private sector, intensified case finding, pro-poor enablers such as nutritional support, TB/HIV collaborative activities, and an increased focus on identifying TB in children.

HIV/AIDS continues to be an important driver of the TB epidemic in Kenya, with approximately 37% of patients with TB also living with HIV (TB/HIV). TB-related deaths among people living with HIV have declined from a high of 12% in 2004 to 5% in 2012, as access to anti-retroviral therapy (ART) and cotrimoxazole preventive therapy (CPT) have increased. Approximately 74% of TB patients co-infected with HIV were initiated on HAART in 2012. Nearly all (98%) HIV infected TB patients were initiated on CPT in the same year (NTLD Program Annual Report 2013).

Programmatic Management of Drug-Resistant TB (PMDT) was initiated in 2007. In 2013, 254 cases of multi-drug resistant TB (MDR-TB) were identified and started on treatment compared to 60 in 2007. Twenty eight percent of notified MDR-TB cases occurred among refugees residing in Kenya. The Kenyan Government made an important humanitarian and public health decision to manage these cases with the resources and infrastructure of the Ministry of Health. WHO currently estimates that there are 2,750 cases of MDR-TB in the country. A drug-resistance survey is ongoing to define the estimates of prevalence of DR-TB in the country.

The number of new leprosy cases detected in the country has declined from 6,000 in 1989 to 139 cases notified in 2013. The health system currently manages grade 1 or 2 disabilities in 48% of the cases notified.

Sustained political commitment for TB has been fundamental to the success of the NTLD Program. Among the performance indicators of the new HSSP is TB treatment success rate, with a goal of reaching 90%. In addition to the government’s commitment, the NTLD Program has nurtured strong partnerships at national and county levels, with donors, international and national NGOs, CSOs, and technical partners through its inter-agency coordinating committees (ICCs). For two consecutive fiscal years of 2013/14 and 2014/15, the National Treasury devolved all funds for TB control to the counties, including commodity procurement funds.

Kenya will remain a legacy in sub-Saharan Africa for being the first country to reach WHO targets for both TB case detection and treatment success. The NTLD Program has successfully managed a high quality program through a cascade of TB and leprosy coordinators at decentralized levels. A network of trained and skilled health workers has consistently enabled the rapid uptake of new policies and technologies, while also providing the platform for supportive supervision to address operational challenges on a systematic basis. The full integration of TB and leprosy service provision into the primary care system has enabled mentorship and decentralized touch points for coordination with community based organizations and care providers.

Kenya maintains a policy of evidence-based strategy development and program implementation. Having the first real-time electronic case-based surveillance system is evidence of the desire for data for action. New approaches, such as the engagement of all care providers and collaborative TB/HIV activities have been successfully scaled up rapidly in Kenya due to the cascade system and the use of evidence of their effectiveness to achieve buy-in at all levels.

Leprosy has also been controlled successfully through the cascade system, and within the primary health care network. Kenya is now in the post-elimination phase of leprosy control.

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2.3.5. Summary of findings from mid-term review 2014

A mid-term review for the just concluded Strategic Plan 2011-2015 was conducted in March 2014 to review progress and give a way forward especially in the changing health context and the new constitutional dispensation. The key findings of this review are highlighted in this section.

Tuberculosis

Treatment success continues to be a hallmark of the NTLD Program, with rates among new smear-positive cases averaging over 88% among HIV-negative patients, 82% among PLHIV, and approximately 68% among those being treated for MDR-TB.

In TB/HIV collaborative activities, over 93% of patients with TB were tested for HIV in 2012. Some 98% of TB/HIV co-infected patients received CPT and 74% were started on ART. The review found that in 75% of facilities visited, TB and HIV services were offered in the same room for patients with TB/HIV. The uptake of TB screening among PLHIV has improved, with 83% screened for TB at their last visit, across the sites visited.

Kenya was one of the first countries in the region to embrace systematic involvement of private providers in TB control, through its Public-Private Mix (PPM) model. In 2012, over 10% of notified cases were reported from the private sector. Kenya was one of the first countries in the region to introduce a nationwide case-based electronic recording system for monitoring program activities known as TIBU. Community engagement in TB control has been facilitated by the roll-out of a national strategy, with an increasing number of civil society organizations and local partners involved. Information, education and communication materials for TB have been developed and disseminated countrywide.

Activities to increase case detection and improve the care of children with TB have also been intensified. Guidelines, on-the-job tools and capacity building activities have been developed. All pediatric formulations of recommended medicines were available in many of the facilities visited. Currently, 11.4% of TB cases notified are in children.

These inaugural and sustained successes have led to what appears to be a steady decline, since 2006, in the case notification rate (CNR), which may resemble a decline in the incidence of TB (Figure 7).

The review acknowledged the presence of three pillars that seem to support the success of the NTLD Program. These include:

1. Sustained government commitment: The government’s financial contribution to TB has increased gradually over the past decade and now accounts for approximately 28% of all spending on TB control in the country. The country has maintained government funding for commodities and a strong staffing structure that extended from the central level to the primary health care system, a key indicator of commitment. Stock-outs of anti-TB medicines at facility level were rarely reported. The review team commended the Government of Kenya on its humanitarian and important public health decision to treat MDR-TB cases among refugees residing in Kenya.

Figure 7: Declining Case Notification Rate suggests decline in TB incidence

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2. Evidence-based Innovation: The NTLD Program has historically adopted innovations in TB control, such as PPM, community-based care and TB/HIV collaborative activities. The Program continues to pilot and scale up new innovations like the nationwide roll-out of TIBU, an electronic case-based recording system. It will enable real-time evaluation of program performance, including early identification of emerging challenges at any level of the health system.

The adoption and rollout of new diagnostic technologies is noteworthy. The country currently has 70 GeneXpert MDR/RIF machines, 5 culture laboratories and 150 LED microscopes; operating within a network of 1,860 AFB microscopy sites (1:25,000 population). Scale-up of GeneXpert represents a tremendous opportunity to rapidly and accurately diagnose and treat TB in people living with HIV and among children, as well as to identify drug resistance.

3. Strong Partnerships: Under solid stewardship by the national government, the NTLD Program benefits from long-standing partnerships with its development and technical partners, especially USAID, Global Fund, WHO, CDC, KNCV, World Bank, GDF, and FIND. In addition, it has been able to mobilize and ensure collaboration with community-based organizations (CBOs), non-governmental organizations (NGOs), Stop TB Partnership, and the private sector. Its sustained engagement with partners through the Inter-Agency Coordinating Committee (ICC) and its five component working groups are to be applauded.

Leprosy Leprosy control is fully integrated in the primary health care network. Kenya’s successful efforts in leprosy control have placed the country in the post-elimination phase.

Figure 8: Declining Notification of Leprosy

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Main Challenges

The NTLD Program is well positioned to emerge as a flagship program within the new health sector strategy, and to contribute to the sector-wide target of a 62% reduction in deaths due to communicable diseases by 2018. To do so, the review team identified challenges relating to:

a) Preventing transmission and diseaseb) finding all TB and leprosy patientsc) ensuring that all TB and leprosy patients are curedd) securing an enabling environment for quality TB control.

Preventing Transmission and Disease

The NTLD Program has excelled in establishing a solid foundation for the control of TB and leprosy disease through the primary health care network. While enhancing the quality of these operations, the NTLD Program can also move into the next era of TB control with an enhanced focus on preventing transmission and disease. Specifically, the team observed limited use of Isoniazid Preventive Therapy (IPT) among PLHIV, and among child contacts of people diagnosed with TB. Infection control (IC) practices were found to be inconsistent, and generally sub-optimal in many health facilities serving patients with TB.

Finding all TB and Leprosy Cases

a) Diagnostic Network: Four broad challenges to timely diagnosis of TB were identified. The first concerns the introduction of new diagnostic technologies. The review noted the absence of an up-to-date strategic plan that articulates the levels of placement and purpose of new technologies. In some cases, the new technologies may replace antique and error-prone methods. For example, the use of GeneXpert as the first diagnostic tool for TB in PLHIV is not yet routine. The second relates to the limited access, high out of pocket cost, inferior quality and challenges with interpretation of radiographs for TB diagnosis. Third, while the coverage of external quality assurance of AFB sputum microscopy was reported as 85%, the review team found inadequate quality testing practices and a lack of timely feedback of results to inform good practice. Mentorship and technical assistance to laboratory technicians was found to be irregular. Financial and geographic barriers to high-quality diagnostic services, especially for children and vulnerable populations, was identified as a main challenge.

b) TB/HIV Collaborative Activities: HIV testing among patients with TB was routinely conducted and monitored. The recording of TB screening among people living with HIV was done but it was not consistently reported through standardized data capture systems. Limited access to diagnostics beyond smear microscopy was noted as a major barrier to clinicians screening for TB among PLHIV.

c) Intensified Case Finding (ICF) activities among contacts of TB and MDR-TB patients remains limited. Barriers to ICF were noted, including the costs of transport, food and radiography.

d) Childhood TB: There remains limited access to diagnostics for childhood TB, especially quality chest radiographs, TST and Xpert. Fee-based testing presents a financial barrier for many families. The team found poor integration between maternal and child health (MCH) clinics, pediatric clinics, emergency rooms and TB service providers. Health care providers at all levels of the health system showed a low index of suspicion for pediatric TB and were not aware of new treatment guidelines.

e) PMDT: Drug resistance testing is limited mostly to retreatment patients, potentially missing cases with primary resistance.

f) Leprosy: The review noted a low index of suspicion for leprosy among health care workers, even in endemic areas.

Ensuring that All Patients are Cured

a) Monitoring and Evaluation: Monitoring, supervision, quality control and evaluation of program activities were sub-optimal at all levels of the system. This deficit was most severe in the diagnostic network. The gaps appeared to be largely associated with a lack of clarity at county-level about the availability of funding for supervision, following devolution. The TIBU system may support more routine monitoring, but it is not yet utilized optimally and there are still challenges in data quality. Capacity to utilize the TIBU – generated local data for decision-making was inadequate.

b) Care for patients with MDR-TB: While the treatment outcomes for PMDT have improved every year since 2008, social and nutritional support for patients remain inconsistent. At the county level, there are limited isolation facilities, absence of functional PMDT clinical teams, and insufficient pharmacovigilance. The high burden of MDR-TB among refugees presents a public health challenge, particularly given the political sensitivities inherent in working with this population.

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c) Community-based care: There were no systematic linkages between providers of community based care and health facilities. This left some community care providers without the needed mentorship and support required to deliver quality care.

d) Social determinants of TB: The World Bank estimates that Kenya’s poverty rate in 2013 was between 34% and 42%. While this is down from 47% in 2005, the social determinants of TB cannot be overlooked. In the Kenyan Demographic and Health Survey of 2009, financial barriers were a primary cause of delayed seeking of health care. The review team identified financial barriers stemming from the following areas: transportation costs, fee-based diagnostic tests, and lack of nutritional and financial support during intensive phase of TB treatment. Malnutrition is known to negatively affect treatment outcomes. The NTLD Program estimated that 17% of notified TB cases were severely malnourished and a further 21% moderately malnourished.

e) Public-private mix: While evidence has suggested that nearly half of care seeking for TB and other lung health issues is done through the private sector, only 10.5% of TB cases were notified by the private sector in 2012. Further scale-up is needed for collaborative public-private mix interventions, which may require a nationwide application of the International Standards of TB Care, particularly through the private providers.

Sustaining government commitment and stewardship in a devolved system

The review acknowledged the potential for devolution to promote patient-centered care by enabling county and sub-county adaptations to relevant service delivery. However, the team also recognized risks that would need to be mitigated to ensure that the successes of a cohesive national program were sustained through the prioritization of TB and consideration of leprosy by all 47 counties.

Key challenges will include:

a) Ensuring a stable and quality assured drug supply: Limited capacity for commodity management was found at all levels of the system. There is no clear process for the procurement of drugs within the new framework despite the counties having the funds for commodity purchase. This needs to be clarified further and adapted with the growing capacity of county governments. A normal procurement cycle can take 6-9 months.

b) Closing the financing gap for TB control: The MTR estimated that the NTLD Program would face a financing gap of nearly US$200 million over the next five years, which represents half of its required funding. Data from the National Health Accounts (NHA) suggested that while TB accounted for over 6% of deaths and nearly 5% of DALYs in the country, it received only 1% of total health expenditures for priority areas. This is in contrast to malaria’s contribution to nearly 6% of deaths and 7% of DALYs, but in receipt of 25% of total health expenditures for priority areas.

c) Ensuring sustained priority for TB prevention and control at central and county levels: TB is not fully considered within the health sector strategy (e.g. the only indicator for TB is treatment success rate), and is not an integral part of the essential health package that has formed the basis for emerging/expanding demand-side, performance-based and social support financing schemes. For example, the direct facility cash transfer program called the Health Sector Services Fund (HSSF) or the health insurance for poor families called the Health Insurance Subsidy Programme (HISP) does not include TB prevention and control services. At county level, health plans were not available for review as they were still being developed, but the inclusion of TB and leprosy activities was not guaranteed.

d) Re-profiling the functions and staff of the central program to support new roles: The functions of the NTLD Program have expanded to include: a) high-level policy formulation to include TB in emerging health system strategies, plans, and demand-side financing modalities including national health insurance and social protection programs; b) coordination of a comprehensive program through guidance/support to 47 counties; and c) continued technical leadership. This places more demand on the NTLD Program staff even as devolution continues. Additional skills, particularly related to economics and statistics are required.

e) Building the capacity of counties and renewing a comprehensive national program: Planning and budget tools to support county-level planning for TB and leprosy control activities, including drug quantification estimates are essential. Counties were unaware of the new funding structures for TB or leprosy control, including supervision and, therefore, activities were not optimal.

f) Shifting epidemiology of TB: The epidemiological profile of TB is bound to change in future due to the potential to detect drug resistance, as well as the improved capacity to detect TB in children and PLHIV, the cross border movement for TB services and the ageing epidemic. There is need to build the capacity of county-level planners to recognize these trends locally and to support relevant activities.

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3.1 Roles and ResponsibilitiesTo achieve the country’s aspirations envisioned in this strategic plan, strong and responsive organizational structures are required to guide the implmentation and monitoring of the Program activities. The exisiting structures, which may evolve with devolution, are anchored on the Constituion of Kenya 2010.

The constitution created two distinct (National and County) Governments that are mutually interdependent with a new level of management and structures that support health services at the County level. The country now has 47 Counties that enjoy relative autonomy in the management of health services. The National Government is made up of three arms: executive, including the Ministry responsible for health, the legislature and judiciary.

The Constitution mandates the National Government with development of Policies, Capacity Building and Technical Assistance to the Counties among other tasks, while empowering the County Governments to be responsible for county health services. These structures are further strengthened by the Kenya Health Policy 2012 - 2030 that provides the framework for seamless implementation of activities. The health service delivery has been reorganized into four tiers of care within which TB, leprosy and lung diseases control programs fit. These are:

• Tier 1: Community Level – as defined in the Kenya Essential Package of Health (KEPH)• Tier 2: Primary Care Level – that provides basic outpatient services• Tier 3: County Level – that provides primary referral services• Tier 4: National Level – that provides secondary and specialized services

The National Leprosy, TB and Lung Disease Program is under the Division of Communicable Disease Prevention and Control in the Directorate of Preventive and Promotive Health Services of the Ministry of Health. Presently, this Program, popularly called Central Program, is made up of technical staff distributed across four sections: Prevention and Health Promotion, Care Services, Policy, Planning and Research (PPR) and Administration and Finance. The Program is linked to the County level through 47 County TB and Leprosy Coordinators (CTLCs), who provide technical and implementation support to 153 Sub-County TB and Leprosy Coordinators (SCTLC).

The overall development of the technical aspects of TB control, including policies, is mandated to the NTLD Program under the umbrella of the Ministry of Health. The NTLD Program has the additional role of setting standards (including providing technical specifications), identifying and mobilizing resources.

The recent increase in global attention to tuberculosis has encouraged local and international partners to support TB control activities in the country. This has created challenges in the coordination of the response of control activities and alignment to the National strategies and policies. The TB Inter Agency Coordination Committee (TB-ICC), initially created to meet the requirements of Global Fund to Fight AIDS, TB and Malaria has shaped the role of all major players in TB control, as membership is all-inclusive. This committee has Technical Working Groups (TWG) that respond to policy matters at scheduled quarterly meetings to deliberate on all issues pertaining to TB control in Kenya.

The Technical Working Groups of the TB ICC include National TB/HIV steering Committee, Laboratory, M&E, MDR-TB, Commodity, ACSM, Community and Gender, Special Groups, PPM and Lung Health. These technical working groups draw membership from both technical and development partners, including affected communities. Some of these working groups have been cascaded to lower levels and hold meetings in stakeholders’ forums where critical issues of implementation and challenges are discussed and addressed.

CHAPTER 3

OPERATIONAL STRUCTURE OF THE NTLD PROGRAM

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3.2. Intra- and Inter-Ministry PartnershipsTuberculosis, Leprosy and Lung diseases prevention, detection, diagnosis, treatment, care and control will benefit from a multidisciplinary approach that identifies and utilizes the varying core competencies of diverse stakeholders, including their complementary resources - human and/or financial, access to presumptive and confirmed patients and their communities, and skills. While a fully multi-sectoral approach to the control of these diseases has not yet been achieved, its appeal is even greater in the context of devolution as a broad array of local stakeholders can optimize the ability to identify local solutions to the contextual nuances of the diseases. To achieve this, thorough mapping of needs and resources at county and sub-county level will be needed. A multipronged approach to working with and through other health and non-health actors, both in the public and private sectors, will be explored for each of the thematic areas covered in this NSP.

a) Public Sector: Inter- and Intra-Ministry collaborations and partnerships

In order to address the diverse social determinants and drivers of TB, leprosy and lung diseases at National and County levels, the NTLD Program will strengthen collaborations and partnerships with relevant departments/sectors within the Ministry of Health, e.g. HIV/AIDS, NHIF, KEMSA, NCDs, etc. In the same breadth, partnerships and collaborations across the Government Ministries/Sectors, which are non-health, will be sought for purposes of resource mobilization, efficiency in resource allocation (e.g. building TB screening into workplace settings), relevant policy formulation and enforcement, establishing forums and platforms for sustained health promotion and education, just to name a few. Such sectors would include but are not limited to:

1. Ministry of Devolution and Planning – for leadership, governance and resource mapping, mobilization and allocation2. The National Treasury – for resource mobilization and allocation3. Ministry of Labor, Social Security and Services - e.g. Workplace health/wellness policies and interventions; resource

allocation for both public and private sectors4. Ministry of Education – for health promotion and education5. Ministry of Defense – for cross border TB6. Ministry Foreign Affairs - for resource mapping, mobilization and allocation7. Ministry of Information, Communication and Technology – for integrating health through ICT8. Ministry of Sports, Culture and the Arts – for health promotion and education9. Ministry of Land, Housing and Urban development – for disease control10. Ministry of EAC Affairs, Commerce and Tourism – for resource mobilization and disease control11. Ministry of Mining – for control of TB and Lung Disease; workplace and labor policies implementation12. Ministry of Interior and Coordination of National Government – for internal migrants and refugees

b) Private Sector: Health and Non Health Actors

The NTLD Program will actively engage the private for-profit and non-profit health actors, at both national and county levels, to support interventions covered within the plan, either directly or indirectly. This will enable systematic application of the relevant standards of care in TB, leprosy and lung health.

Partnering with the private non-health actors may enable new avenues for resource mobilization, enhanced advocacy for the implementation of health policies, among other areas of involvement. If well engaged and sensitized, this sector may contribute substantially towards health through integrating/mainstreaming health in their core business, offer support through their core competencies, or even contribute towards health resources in kind or in cash. Examples exist in Kenya of innovative corporate partners supporting health care, but commonly at a small scale or through corporate social responsibility (CSR) programs.

The Stop TB Partnership in Kenya has been revitalized to spearhead the multi-sectoral approach for purposes of building synergy from the diverse competencies, through an advocacy and resource mobilization platform.

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4.1. NSP Goals and Objectives Within the context of a newly devolved health system, the goal of the 2015-2018 NSP is to accelerate the reduction of TB, leprosy and lung disease burden through provision of people-centered, universally accessible, acceptable and affordable quality services in Kenya.

Specific objectives include:a) Sustain the gains made over the past decade, in the context of a newly devolved health systemb) Intensify efforts to find the “missing” cases of TB, leprosy and lung disease; c) Reduce transmission of TB and leprosy;d) Prevent active disease and morbidity; e) Enhance the quality of care for chronic diseases

4.2. Impact and Outcome TargetsThe NSP seeks to achieve the following by 2018:

CHAPTER 4

2015-2018 NATIONAL STRATEGIC PLAN

IMPACT AND KEY OUTCOME INDICATORS

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

Outcomes

1. Increase case notification of new cases to 85% of estimated prevalence

2. Ensure treatment success of at least 90% among all drug – susceptible forms of TB

Impact 1.1. Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014

Outcomes

1. Increase case notification of MDR-TB to at least 75% of estimated prevalence (Baseline TBD: DR Survey)

2. Increase treatment success rate to at least 80% among all cases of DR-TB

Impact 1.2. Reduce the incidence of TB among PLHIV by 60% by 2018 compared to 2014

Outcomes

1. Increase treatment success rate to 85% among all HIV-infected TB patients

2. Reduce case fatality among HIV-infected TB patients to <5%

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IMPACT AND KEY OUTCOME INDICATORS

Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014

Outcomes

1. Ensure treatment success of at least 90% among all DS forms of TB

2. Reduce case fatality among HIV-infected TB patients to <5%

Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy & other lung diseases by 2018 (baseline TBD)

Outcomes

1. Increase to at least 60% the proportion of eligible TB and leprosy patients who access nutritional support or other transport, or financial subsidies

2. Reduce out-of-pocket expenditures attributed to TB care seeking

Impact 4: Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018

Outcomes

1. Increase to 90% the proportion of leprosy patients notified prior to grade 2 morbidity

Impact 5: Reduce morbidity due to chronic lung diseases (e.g. COPD, asthma)

Outcomes

1. Reduce the average number of annual acute episodes for children with asthma by 15% in areas with established asthma clinics

2. Increase to 80% the proportion of controlled asthma patients

Table 2: NSP Impact and Key Outcome Indicators

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4.3. Eliminate Communicable Diseases

4.3.1 Devolve implementation of activities and budgets

1. Situational Analysis (SWOT)

Sustained political commitment to TB has been fundamental to the past success of the NTLD Program.

In addition to the government’s commitment, the NTLD Program has nurtured strong partnerships at national and decentralized levels. International and national NGOs, CSOs, technical and development partners have been engaged to benefit the plan.

The NTLD Program has successfully managed a high quality program through a cascade of TB and leprosy coordinators at decentralized levels; i.e. provincial and district level prior to devolution. The network of trained and skilled health workers has consistently enabled the rapid uptake of new policies and technologies, while also providing the platform for supportive supervision to address operational challenges on a systematic basis. The full integration of TB and leprosy service provision into the primary care system enabled mentorship and decentralized touch points for coordination with community based organizations and care providers.

Devolution presents opportunities for local prioritization and adaptation of TB and leprosy control, and support for targeted and patient-centered care. Since fiscal year 2013, all government funds for TB control have devolved to the counties, including funds for commodity procurement. In accordance with the Constitution, all devolved funds were bundled and no line item for health, or TB, was specified.

Translating the cascade model of technical excellence and assistance into the new structure is ongoing and will require additional human resources and new skill sets, given the expanded number of administrative units and new requirements for planning capacity at county level.

2. Strategic Direction(s) for 2015-2018

The priority in this period is to ensure a smooth transition to the county-based system of governance. Specifically, the NTLD Program, NTRL and county health offices will collaborate to ensure that a comprehensive national program is maintained within the devolved context. At a minimum, joint annual work plans between the Central Program and each county will be needed to yield a national plan built on county priorities.

3. Proposed Approaches

Establish Inter-Governmental Agreements between the NTLD Program and NTRL and each county

a) Articulate and document the devolution of responsibilities for all TB activities: i.e. considering all dimensions of program implementation and detailing which will be completed by central, county and sub-county levels (NTLD Program Operations Manual 2014)

b) Define financial and human resource commitments, including technical assistance and possibly commodity management support from central program(s).

Bolster county-level capacity for planning for TB, leprosy and lung health

a) Ensure the county and sub-county structure can support all designated activities: e.g. identify a TB and leprosy focal point for each level, take inventory and address any capacity building needs; and develop on-the-job tools and disseminate existing guidance to promote national standards.

b) Support and monitor the inclusion of TB and leprosy within county health plansi) Develop a template(s) for planning and budgeting of TB control activities, including commodity requirements, for use at county level.

ii) Annual joint work planning between the NTLD Program and each county, ensuring TB and leprosy are appropriately represented in health plans. Detailed technical assistance plans will be included in each county

19

plan. Commodity estimates, based on past utilization, will be completed annually for inclusion in county health plans. The NTLD Program will monitor expenditures on TB through the NHA sub-account and via expenditure tracking from Treasury to facilities

iii) Stakeholder mapping will be completed at all levels, and annual planning meetings held to engage stakeholders in county planning

Establish County-based centres of excellence, based on strong performance, for: a) PMDTb) Pediatric TBc) TB/HIVd) Diagnostic services e) PPMf) PALg) Community engagementh) Leprosy

Incentivize counties to serve as models and enable county-to-county technical assistance.

Develop and implement a technical assistance and quality assurance plan through a cascade from central to community levels

Given that many of the county and sub-county staff are new, capacity building will be required for TB and leprosy focal point persons in the counties. The nature of technical assistance from central to county level must be expanded to build capacity for planning, advocacy, budgeting, quality assurance of labs and facilities, and data monitoring.

Ensure county ownership and designated funding of supportive supervision to sub-counties, health facilities, laboratories and community-based treatment partners. Ensure implementation of technical standards including updated SOPs for new diagnostic technologies, and treatment protocols for management of TB e.g. pediatric and drug-resistant TB. Revise the tools available to guide county-level staff in their supervision of more decentralized levels, based on the new county structure.

Specific activities include:

a) Creation of on-the-job tools to serve as reference to key policy and implementation principles. As the infrastructure to support electronic data management, potential for web- based refresher training may be optimized to address the ongoing training needs that result from high staff turnover.

b) Promote the establishment of inter-agency coordinating committees to assist with planning, budgeting, implementing and monitoring activities. The ICCs include all partners, such as the private sector, MCH programme, CSOs and communities, at county and sub-county levels.

c) Establish and disseminate technical standards to guide delivery of services at County level and create buy-in for their implementation and monitoring.

d) Re-profile the staff of the central program to ensure in-house capacity for: i) high-level policy formulation to include TB in emerging health system strategies, plans, and demand-side financing modalities including national health insurance and social protection programmes; ii) coordination of health system structures for comprehensive program implementation to 47 counties; and iii) continued technical leadership. Additional skills, particularly related to economics and statistics, are required at the Program level.

20

4.3.2 Identify and treat all cases (find

the missing cases)

4.3.2.1. Core DOTS

1. Situational Analysis

TB incidence has shown a declining trend as illustrated in Figure 9. It is estimated that nearly 80% of new TB cases were notified in 2013. Map 1 and Figure 12 reflect case notification rates by county, showing the wide inter-country variance of case notification. It is not known if the variance reflects true epidemiological differences, but it can certainly be assumed that cases are missed in all counties to varying degrees.

During the last five years, the program has maintained a national treatment success rate above 85% as shown in Figure 10. Map 2 reflects cases that are lost to follow up, also known as ‘out-of-control.’ Figure 11 shows treatment success rates by county, similarly highlighting the variance in programmatic performance across the country.

Considering the well-documented relationship between poverty and TB, areas of lower case notification and high poverty density may provide hints as to the location of some of the 20% of cases that are undetected. Figure 12 shows markedly lower case notification rates in some counties that have high rates of poverty prevalence i.e. percentage of households that are below the poverty line. Nationwide, approximately 45% of households are estimated to live below the poverty line.

Figure 9: TB Incidence

Figure 10: Treatment Success for Notified Cases

Map 1: Case Notification Rates, 2013

4.3.

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21

Map 2: Lost to Follow Up Rate, 2012

4.3.2.1. Core DO

TS

Figure 11: Overall Case Notification and Treatment Success Rates by County, 2012

22

The NTLD Program is planning a national prevalence survey to be completed during 2014-2015, which will provide more evidence regarding at-risk groups that are under-served by the current network of providers. Until the prevalence survey is completed, data from the national M&E system and operational research studies must guide the Program’s priority setting.

Based on existing evidence from within Kenya and other neighboring countries, the following high-risk groups are recognized as hosting disproportionately high rates of TB and/or being underserved by health services:

a) Urban slums: While the incidence of TB in slum areas throughout Kenya is not known, slums are considered a high-risk setting given the ease of transmission due to overcrowding and financial, geographical and social barriers to care. A pilot project launched under TB-REACH in 2010 to provide affordable and accessible services in Kibera, an urban slum near Nairobi, has increased case notifications by 10%.

b) Health care workers: In Kenyatta National Hospital, a study showed that the rate of TB among health care workers was three times higher than in the surrounding community. In 2011, the notification rate was the equivalent of 772/100,000. Only 75% of cases among health care workers during 2006-2011 successfully completed treatment.

c) Mobile/migrant populations: Kenya is host/home to diverse migrant populations. Ethnic conflict, cattle raids, and climate change have driven internal movement and displacement. Labor-related movement between plantations across rural areas is common. Social determinants arising from migration, such as living in cramped settlements, and income and food instability, increase the risk of TB. Access to continuous care is constrained by many of the social dimensions of migration1.

d) Refugees: Kenya absorbs migrants and refugees from Sudan, Somalia, Ethiopia, Tanzania and Uganda. While WHO estimates the incidence rate of TB to be similar in countries from which many of the refugees in Kenya originate, refugees currently account for 30% of all of the MDR-TB cases notified in the country.

e) Prisoners: TB case notification rates in two large prisons in Kenya, Meru and Embu, were 941 and 4,714/100,000 respectively in 2012. These rates are 4-10 times higher than in the surrounding population. It is estimated that similarly disproportionately high rates occur in other prison settings.

_______________________________________________________________________________________________________________________________1 International Organization for Migration, 2011: An Analysis of Migration Health in Kenya

4.3.

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Figure 12: Case Notification Rate by Prevalence of Poverty, by County

23

f) Uniformed service personnel: Long recognized as a high-risk group for HIV infection in Kenya, this cadre of government personnel is relatively at higher risk for TB.

g) People living with HIV: A study2 suggested that the incidence of TB is 8 times higher among PLHIV in Kenya.

h) Contacts of TB patients: Limited evidence is available from country-level practice regarding the benefits of contact tracing. However, the WHO global recommendation in favor of screening of close contacts of active TB patients is based on five cross-sectional studies showing that contact tracing contributed 2-19% of all cases, and two randomized control trials showing a 15% reduction in incidence and 22% reduction in prevalence due to contact tracing3.

i) Diabetics: While less recognized than its relationship with HIV, TB is 2.5 times more likely to strike in people with diabetes. The International Diabetes Federation predicts the prevalence of diabetes in sub-Saharan Africa to rise by 98.1% between 2010 and 20304.

j) Moderately and severely malnourished individuals: The importance of nutrition for patient recovery has been documented in several studies as a key intervention to improve treatment outcomes and an incentive to promote treatment adherence. Almost 20% of all TB patients were severely malnourished in 2013; i.e. BMI<16. More than a quarter (27.4%) of severely malnourished patients did not receive any form of nutritional support.

The NTLD Program has established policies, strategies and guidelines that are in line with international recommendations and lessons learned from Kenya. The operationalization of national norms occurs through service delivery that is fully integrated into the public health network. Dedicated TB and leprosy coordinators assigned at devolved levels provide supportive supervision to sub-counties and health facilities.

Structured quality assurance for diagnosis and treatment, as well as case-based monitoring and evaluation provide the foundation for ensuring the quality of the program. Currently, one TB treatment or follow-up center serves fewer than 15,000 people. However, despite efforts to build capacity for TB prevention, detection and care at all levels of the health system, it is estimated that fewer than 40% of dispensaries are able to provide TB treatment.

2. Strategic Direction(s) for 2015-2018

The priorities for this period are to:

a) Ensure treatment success rate of at least 90% nationally among all drug-susceptible (DS) forms of TB.

b) Reach marginalized, high-risk and under-served populations, closing the case detection gap

c) Incorporate TB into existing and emerging social protection schemes, including nutritional support platforms.

_______________________________________________________________________________________________________________________________2 Comparison of Trends in Tuberculosis Incidence among Adults Living with HIV and Adults without HIV – Kenya, 1998–2012Courtney M. Yuen1, Herman O. Weyenga2, Andrea A. Kim3, Timothy Malika2, Hellen Muttai3, Abraham Katana3, Lucy Nganga3, Kevin P. Cain3*, Kevin M. De Cock33 Feasibility, yield, and cost of active tuberculosis case finding linked to a mobile HIV service in Cape Town, South Africa: a cross-sectional study.Kranzer1, Lawn SD, Meyer-Rath G, Vassall A, Raditlhalo E, Govindasamy D, van Schaik N, Wood R, Bekker LG., 20124 International Diabetes Federation. IDF Diabetes Atlas, 5th edn. Brussels, Belgium: International Diabetes Federation, 2011. http://www.idf.org/diabetesatlas

STRATEGIC OBJECTIVES

4.3.2.1. Core DO

TS

24

3. Proposed Approaches

The proposed approaches reflect activities that will be needed nationwide to sustain a cohesive national program, in addition to targeted approaches that address specific epidemiological and programme performance contexts.

Sustain quality programme implementation

At the heart of this NSP is the acknowledgement that the NTLD Program has achieved important milestones in terms of case notification and treatment success. The factors contributing to these successes must be sustained nationwide while aligning to the newly devolved governance structure.

Among the key arrangements to be sustained are:

a) Human resource capacity, in sufficient numbers and adequately trained and supported to fully implement the activities of this NSP.

Specifically:

i. TB and leprosy dedicated staff at national, county and sub-county levels: This concerns the continued availability of TB and leprosy dedicated staff with technical expertise to guide implementation across the system.

ii. Technical assistance to counties to ensure technical excellence and the appropriate application or adaptation of national guidelines will reflect specific needs/gaps in counties (Tables 3- 4). Regular technical assistance from the central program or more devolved centers of excellence to individual counties is anticipated on a quarterly basis.

iii. Supportive supervision to systematically extend capacity building and knowledge sharing from the county to sub-county, health facility and community levels. Supportive supervision is planned in a cascade manner, on a monthly basis.

iv. Training and professional development tailored to the specific epidemiological and program performance contexts of each county, sub-county and facility type. Innovative formats for cost-efficient continuing education, such as web-based training, android applications and other on-the-job tools will be developed.

v. International technical assistance to enable continuous innovation and evidence-based program evolution that is enhanced by learning from other countries and experts.

b) Normative functions, guidelines and tools

The normative role of the central program has not changed with the devolution of other responsibility to counties. Gradual updating of all guidelines to align with implementation through the newly devolved system will be required.

i. Guidelines: Guidelines will be updated as new technical standards emerge internationally and/or where local evidence drives a policy shift.

ii. Training tools: Updated planning, budgeting and technical training tools will be required to support devolution and the roll-out of new approaches

iii. Information Technology (IT): Pilot testing and roll-out of new IT solutions to enhance patient-centered care, such as SMS treatment reminders, are planned

iv. Data management system: Continued enhancement of TIBU is detailed in the M&E section

c) Coordination forums

The 2014 mid-term review cited the strength of programme coordination internally and with partners as central to its success. Among the forums to be sustained with regular meetings and follow-up activities are the:

i. Technical working groupsii. Inter-agency coordinating committeeiii. Stop TB Partnershipiv. Data dissemination forums.

d) Stable supply of commodities including drugs, laboratory supplies and equipment, vehicles, and stationery, as described in the commodities section of this NSP.

Target activities to increase case notifications and treatment success

This NSP aims to reduce the disparities between counties in terms of case detection and treatment success, elevating and sustaining programmatic performance at a high level within each county. It is expected that treatment success will reach at least 90% in all counties, and all counties will make targeted efforts to increase case notification.

An assessment of the county-specific epidemiological and programme performance contexts is provided in Table 3

4.3.

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Cor

e D

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25

and Figure 12. Based on each county’s context, intensified effort will be given to scaling up proven interventions as described below:

a) Package 1: TB Case Notification Rate <175/100,000

16 counties have case notification rates at or below 175/100,000.

While it is recognized that incidence may be lower in these counties, ensuring that capacity exists to detect and diagnose cases is a priority.

In these counties, intensified effort will be given to:

i. Build capacity of health workers and laboratory technicians to identify and diagnose TB

ii. Employ active case finding, with county-based tailoring of the modalities and target groups

iii. Strengthen implementation and monitoring of systematic TB screening at health facility, in-patient wards and community levels, with improved documentation of presumptive TB cases and linkages to diagnostic and care sites

iv. Engage all care providers with an emphasis on systematic screening for TB and reporting of presumptive and active cases, through private, NGO, CSO, MCH and HIV-specialty care facilities

v. Expand communication efforts in communities to stimulate care seeking

vi. Ensure the availability of referral networks for sputum samples and patient care

vii. Intensify technical assistance and supportive supervision from Centers of Excellence or the NTLD Program

4.3.2.1. Core DO

TS

Evidence for Targeting

Case Notifications

• 16 counties have low TB case notification (<175/100,000)

• 10 counties have relatively high TB caseloads (around or above 250/100,000)

• Case notification rates are loosely, yet inversely related to the prevalence of poverty in counties, suggesting missing cases among the poor

Treatment Successes

• 27 counties have treatment success rates below 88%

Defaulters

• Three counties; Nairobi, Meru and Mombasa account for 27% of all cases notified, but 36% of cases of treatment default

• 9 counties have default rates >7%

Box 1b) Package 2: TB Case Notification Rate 175-250/ 100,000

There are 22 counties with case notification rates between 175 – 250/100,000. In these counties, assessment of the sub-county epidemiology and programme performance will shape the focus of intensified case finding or other tailored approaches. Capacity in these counties should be sufficient to deploy active contact tracing, especially among child contacts of active TB cases and PLHIV.

c) Package 3: Case Notification Rate >250/100,000

There are nine (9) counties with case notification rates near or above 250/100,000. These counties may host successful models of case finding and human resource expertise that can be shared in other counties. Center(s) of Excellence within these counties will be established to serve as referral points, and to host HCWs and TB and leprosy coordinators from other counties for on-site mentorship, training and technical assistance.

These counties may also host particularly high incidence among sub-populations. Intensified efforts to reach high-risk groups will be supported. Contact tracing will be further enhanced.

d) Package 4: Treatment success <88%

In 27 counties, treatment success rates in 2012 were below the national target of 88%. In these counties, intensified efforts will be mobilized for:

i. Defaulter tracingii. Strengthen access to critical enablers i.e. nutrition support and other social protections iii. Improved health education for patients, including innovations in the use of technology platforms for communicating

with patientsiv. Building CHEW capacity to oversee family-based and community volunteer-supported DOTv. Strengthen referral networks to bring care closer to patients.

e) Package 5: Poverty prevalence > 45%

There are 26 counties in which >45% of households live below the poverty line. The poorest TB patients face particular socio-economic barriers to care that will be addressed through:

i. Strengthening access to social protections, especially nutritional support, transport vouchers, and health insurance.

26

ii. Strengthening referral networks, such as sputum collection points to connect to laboratories, to bring care closer to patients

iii. Prioritize the engagement of communities

County-specific needs to be addressed are summarized in the following table:

County-Specific Contexts

COUNTY Low CNR (< 175/ 100,000)

Mid CNR ( 1 7 5 - 2 5 0 / 100,000)

Low treatment success (< 88%)

High poverty prevalence (> 45%)

>40% of TB patients with BMI < 18

High HIV prevalence in general population (>5%)

HIV prevalence 2.5-5%

Low community case notification ( < 9% of total)

Low pediatric case notification (<8% of total)

Baringo X X X X X X X

Bomet X X X X X

Bungoma X X X X X X

Busia X X X X

Embu X X X X

Garissa X X X X

Homa Bay X X X

Isiolo X X X X X

Kajiado X X X X X

Kakamega X X X X X

Keiyo-Marakwet X X X X X

Kericho X X X X

Kiambu X X X X X

Kilifi X X X X X

Kirinyaga X X X X X

Kisii X X X X X X

Kisumu X X X X

Kitui X X X X X X X

Kwale X X X X X X

Laikipia X X X X X X X

Lamu X X X

Machakos X X X X X X X

Makueni X X X X X X

Mandera X X X X

Marsabit X X X X X

Meru X X X X X X

Migori X X X X

Mombasa X X X

Murang'a X X X X X X

Nairobi X X X X

Nakuru X X X X X

Nandi X X X X X X

Narok X X X X X

Nyamira X X X

Nyandarua X X X X X X

Nyeri X X X X X

Samburu X X X X X X

Siaya X X X X X

Taita Taveta X X X X X X

Tana River X X X X X X

Tharaka X X

Trans Nzoia X X X X X

Turkana X X X X X

Uasin Gishu X X X X

4.3.

2.1.

Cor

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27

Expand special initiatives to reach most at-risk

The most at-risk populations defined above warrant targeted approaches. Successful pilots will be scaled-up and new approaches introduced with attention to monitoring the impact on case notification and treatment outcomes. The table below summarizes the approaches by high-risk group:

High-Risk Group Approaches

Health care workers Implement infection control plans in all government health facilities

Conduct annual screening for HCWs as part of a revised workplace-based policy on TB control

Assess and respond to socio-economic barriers to treatment initiation and treatment completion

Prisoners

Implement screening upon entry to prisons

Enhance infection control practices

Introduce diagnostic and DOT capacity on-site

Develop health education tools for prisoners and prison staff

Develop referral mechanisms for prisoners who are transferred or released

Mobile populations Integrate TB screening and control activities within service delivery platforms reaching these populations; e.g. MCH mobile outreach, HIV activities along transport corridors

Refugees Enhance infection control capacity within camps

Ensure diagnostic and DOT capacity, including Rif-resistance identification (Xpert), on-site

Uniformed service Introduce diagnostic and DOT capacity on-site

Update the workplace-based policy to allow 1 month of paid leave for new cases

Intensify contact tracing

Urban slums Intensify community engagement and outreach

Increase the engagement of non-state providers already present in the slums or reaching slum dwellers, including employers

Expand the availability of diagnostic sites and/or referral networks, including sputum collection points, to bring services closer to patients

Expand eligibility of social protection programs to include TB patients

Diabetics Pilot systematic screening for TB among all diabetics followed by hospitals and other providers (Year 1); and screen TB patients for diabetes (Year 3)

Table 4: Approaches by High-Risk Group

COUNTY Low CNR (< 175/ 100,000)

Mid CNR ( 1 7 5 - 2 5 0 / 100,000)

Low treatment success (< 88%)

High poverty prevalence (> 45%)

>40% of TB patients with BMI < 18

High HIV prevalence in general population (>5%)

HIV prevalence 2.5-5%

Low community case notification ( < 9% of total)

Low pediatric case notification (<8% of total)

Vihiga X X X X

Wajir X X X X

West Pokot X X X X X

Table 3: County Specific Contexts

4.3.2.1. Core DO

TS

28

Contribution to NSP Impacts Outcomes (Core DOTS)

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

Increase case notification (in each county) of new cases to 85% of estimated prevalence

Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014

Increase the treatment success rate among HIV-infected TB patients to 85%

Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014

Ensure treatment success rate (in each county) of at least 90% among all DS forms of TB

Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy & other lung diseases, by 2018 (baseline TBD)

Increase to 100% the proportion of severely and moderately malnourished people with TB who access appropriate nutritional support

Table 5: Impact and Outcome Indicators for Core DOTS

4.3.

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29

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50

cl

inic

al

offi

cers

an

d

115

labo

rato

ry

tech

nolo

gist

s

175

Num

ber

of

staf

f su

ppor

ted

to

unde

rtak

e pr

ofes

sion

al c

ours

es a

t th

e K

enya

Sch

ool o

f G

over

nem

ent

Supp

ort

sta

ff f

rom

NTL

D P

rogr

am a

nd c

ount

ies

to

unde

rtak

e pr

offe

sion

al c

ours

es a

t K

enya

Sch

ool

of

Gov

ernm

ent

Supp

ort

sta

ff f

rom

NTL

D P

rogr

am

and

coun

ties

to

un

dert

ake

prof

fesi

onal

co

urse

s at

K

enya

Sc

hool

of

Gov

ernm

ent

60Su

ppor

t s

taff

fro

m N

TLD

Pr

ogra

m

and

coun

ties

to

un

dert

ake

prof

fesi

onal

co

urse

s at

Ken

ya S

choo

l of

G

over

nmen

t

60Su

ppor

t s

taff

fro

m N

TLD

Pr

ogra

m

and

coun

ties

to

un

dert

ake

prof

fesi

onal

co

urse

s at

Ken

ya S

choo

l of

Gov

ernm

ent

60Su

ppor

t s

taff

fro

m N

TLD

Pr

ogra

m

and

coun

ties

to

un

dert

ake

prof

fesi

onal

co

urse

s at

Ken

ya S

choo

l of

Gov

ernm

ent

60

Num

ber

of s

taff

sup

port

ed t

o at

tend

in

tern

atio

nal c

ours

es

Supp

ort

staf

f fr

om N

TLD

and

cou

ntie

s to

att

end

inte

rnat

iona

l cou

rses

Supp

ort

staf

f fr

om N

TLD

Pro

gram

an

d co

unti

es t

o at

tend

inte

rnat

iona

l co

urse

s

6Su

ppor

t st

aff

from

N

TLD

Pr

ogra

m

and

coun

ties

to

at

tend

in

tern

atio

nal

cour

ses

6Su

ppor

t st

aff

from

N

TLD

Pr

ogra

m

and

coun

ties

to

at

tend

in

tern

atio

nal

cour

ses

6Su

ppor

t st

aff

from

N

TLD

Pr

ogra

m

and

coun

ties

to

at

tend

in

tern

atio

nal

cour

ses

6

Num

ber

of a

udit

ors

trai

ned

on IS

OTr

ain

inte

rnal

aud

itor

s on

ISO

Trai

n in

tern

al a

udit

ors

on IS

O5

Trai

n in

tern

al

audi

tors

on

IS

O5

Trai

n in

tern

al a

udit

ors

on

ISO

5

Num

ber

of l

ead

audi

tors

tra

ined

on

ISO

Trai

n le

ad a

udit

ors

on IS

OTr

ain

lead

aud

itor

s on

ISO

2Tr

ain

ISO

lead

aud

itor

s2

Num

ber

of

NTL

D

Prog

ram

st

aff

sens

itiz

ed o

n IS

OSe

nsit

ize

NTL

D P

rogr

am s

taff

on

ISO

Sens

itiz

e N

TLD

Pro

gram

sta

ff o

n IS

O40

Sens

itiz

e N

TLD

Pr

ogra

m

staf

f on

ISO

40

ISO

ce

rtif

icat

ion

reta

ined

by

N

TLD

Pr

ogra

mM

eet

ISO

cer

tifi

cati

on r

equi

rem

ents

for

ret

enti

on

incl

udin

g fe

esA

nnua

l ISO

fee

s1

Ann

ual I

SO f

ees

1A

nnua

l ISO

fee

s1

Ann

ual I

SO f

ees

1

Num

ber

of C

TLC

s or

ient

ed a

nnua

llyCo

nduc

t IS

O o

rien

tati

on t

rain

ing

for

CTL

Cs

Cond

uct

ISO

orie

ntat

ion

trai

ning

fo

r C

TLC

s30

Cond

uct

ISO

orie

ntat

ion

trai

ning

for

CTL

Cs

30Co

nduc

t IS

O

or

ient

atio

n tr

aini

ng f

or C

TLC

s30

Cond

uct

ISO

orie

ntat

ion

trai

ning

for

CTL

Cs

30

1.2

Nor

mat

ive

Func

tion

s, G

uide

lines

and

Too

ls

4.3.2.1. Core DO

TS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Perc

enta

ge o

f 'r

etre

atm

ent'

pat

ient

s st

arte

d on

cat

egor

y 2

reg

imen

D

evel

op a

pol

icy

for

pha

sing

out

TB

Cat

egor

y II

regi

men

TWG

to

phas

e ou

t C

AT

II re

gim

en1

Dis

sem

inat

ion

of g

uide

lines

and

sen

siti

zati

on10

0%D

isse

min

atio

n of

ne

w

guid

elin

es o

n ph

asin

g ou

t of

C

AT

II re

gim

en

80%

Pati

ents

re

ceiv

ing

CA

T II

regi

men

60%

Pati

ents

re

ceiv

ing

CA

T II

regi

men

40%

Num

ber

of

trai

ning

ne

eds

asse

ssm

ents

co

nduc

ted

and

diss

emin

ated

Trai

ning

nee

ds a

sses

smen

t (T

NA

) to

ide

ntif

y th

e ga

ps a

nd o

ppor

tuni

ties

of

the

curr

ent

TB t

rain

ing

curr

icul

um

Nat

iona

l tr

aini

ng

need

s as

sess

men

t (T

NA

) to

id

enti

fy

the

gaps

an

d op

port

unit

ies

of t

he c

urre

nt

curr

icul

um

1_

Stak

ehol

ders

mee

ting

s to

dis

sem

inat

e fi

ndin

gs o

f th

e TN

A a

nd s

hare

nee

d fo

r cu

rric

ulum

rev

iew

Stak

ehol

ders

m

eeti

ngs

to

diss

emin

ate

find

ings

of

the

TNA

an

d sh

are

need

fo

r cu

rric

ulum

rev

iew

1

Stak

ehol

der

mee

ting

s to

de

velo

p re

quir

ed

com

pete

ncie

s of

dif

fere

nt c

adre

s in

TB,

lep

rosy

&

lu

ng

dise

ase

serv

ice

deliv

ery

(bas

ed

on

TNA

fe

edba

ck a

nd s

take

hold

er i

nput

) an

d de

velo

pmen

t of

a c

urri

culu

m f

ram

ewor

k ba

sed

on t

he o

utpu

t of

th

e w

orks

hops

Tech

nica

l w

orki

ng

grou

p m

eeti

ngs

to

deve

lop

requ

ired

co

mpe

tenc

ies

of

diff

eren

t ca

dres

in

TB

, le

pros

y &

lu

ng

dise

ase

serv

ice

deliv

ery

(bas

ed

on

TNA

fe

edba

ck

and

stak

ehol

der

inpu

t)

and

deve

lopm

ent

of

a cu

rric

ulum

fr

amew

ork

base

d on

the

out

put

of t

he

wor

ksho

ps

An

inte

grat

ed T

B tr

aini

ng c

urri

cullu

mD

evel

op a

n in

tegr

ated

TB

trai

ning

cur

ricu

lum

n/a

Cond

uct

wri

ting

wor

ksho

ps

to c

onve

rt p

revi

ous

trai

ning

m

ater

ials

in

to

dist

ance

le

arni

ng

form

at

(incl

uded

tr

aini

ng

in

wri

ting

in

th

is

form

at)

n/a

Tech

nica

l re

view

w

orks

hops

by

ex

pert

s in

th

e di

ffer

ent

mod

ules

(an

d de

velo

pmen

t of

ad

junc

t m

ater

ial

– te

sts,

log

boo

ks

etc.

)

n/a

Wri

ting

w

orks

hops

to

co

nver

t pr

evio

us

trai

ning

m

ater

ials

in

to

dist

ance

le

arni

ng

form

at

(incl

uded

tr

aini

ng i

n w

riti

ng i

n th

is

form

at)

1

Educ

atio

nal

revi

ew o

f th

e m

odul

esn/

an/

a

Pilo

t of

the

cur

ricu

lum

at

sele

cted

sit

es c

ount

ry-w

ide

Eval

uati

on o

f th

e pi

lot

Post

-pilo

t re

view

w

orks

hops

fo

r fe

edba

ck

from

pilo

t sit

es a

nd re

visi

on

of c

urri

culu

m m

ater

ials

Educ

atio

nal

revi

ew

and

fina

l edi

ting

Roll

out

incl

udin

g m

onit

orin

g

A

TB

tech

nica

l as

sist

ance

m

anua

l de

velo

ped

Supp

ort

deve

lopm

ent

and

dis

sem

inat

ion

of a

TB

tech

nica

l ass

ista

nce

man

ual

Cond

uct

TWG

s m

eeti

ngs

on

de

velo

pmen

t of

TA

man

ual

n/a

Dis

sem

inat

ion

of T

A m

anua

ln/

a1

n/a

4.3.

2.1.

Cor

e D

OTS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Num

ber

of T

B co

ntac

t tr

acin

g to

ols

and

defa

ulte

r tr

acin

g to

ols

pri

nted

Dev

elop

too

ls f

or c

onta

ct t

raci

ng o

f TB

pat

ient

sRe

vise

/dev

elop

def

ault

er t

raci

ng

&

cont

act

trac

ing

tool

s to

inco

rpor

ate

cont

act

trac

ing

& T

B sc

reen

ing

in a

ll cl

inic

al s

etti

ngs

tool

s

15,0

0015

,000

15,0

0015

,000

Prin

t TB

con

tact

tra

cing

too

lsPr

int

5,00

0 co

ntac

t tr

acin

g bo

okle

ts,

5,00

0 co

ntac

t re

gist

ers,

5,

000

defa

ulte

r tr

acin

g bo

okle

ts

Prin

t 5,

000

cont

act

trac

ing

book

lets

, 5,

000

cont

act

regi

ster

s,

5,00

0 de

faul

ter

trac

ing

book

lets

Prin

t 5,

000

cont

act

trac

ing

book

lets

, 5,

000

cont

act

regi

ster

s,

5,00

0 de

faul

ter

trac

ing

book

lets

Prin

t 5,

000

cont

act

trac

ing

book

lets

, 5,

000

cont

act

regi

ster

s,

5,00

0 de

faul

ter

trac

ing

book

lets

Dis

sem

inat

ion

of c

onta

ct t

raci

ng t

ools

Cond

uct

a na

tion

al

diss

emin

atio

n w

orks

hop

and

deve

lop

and

rapi

d ad

vice

sen

t to

all

coun

ties

__

Num

ber

of T

B in

tens

ifie

d ca

se f

indi

ng

tool

s de

velo

ped

and

prin

ted

Supp

ort

prin

ting

of

algo

rith

ms,

SO

Ps &

pro

toco

ls

on T

B-D

M a

nd e

xten

ded

TB In

tens

ifie

d ca

se f

indi

ngSu

ppor

t pr

inti

ng

of

algo

rith

ms,

SO

Ps

&

prot

ocol

s on

TB

-DM

an

d ex

tend

ed

TB

Inte

nsif

ied

case

fin

ding

5000

Num

ber

of

coun

ty

diss

emin

atio

n w

orks

hops

for

TB-

DM

and

inte

nsif

ied

case

fin

ding

too

ls c

ondu

cted

Dis

sem

inat

ion

of T

B-D

M a

lgor

ithm

s to

all

coun

ties

n/a

n/a

Cond

uct

diss

emin

atio

n m

eeti

ngs

of

algo

rith

ms,

SO

PS a

nd p

roto

cols

on

TB -

D

M a

nd e

xten

ded

ICF

24Co

nduc

t di

ssem

inat

ion

mee

ting

s of

al

gori

thm

s,

SOPS

and

pro

toco

ls o

n TB

-

DM

and

ext

ende

d IC

F

23n/

an/

a

1.3

Coor

dina

tion

For

a

Num

ber

of n

atio

nal

TWG

mee

ting

s he

ldSu

ppor

t qu

arte

rly

nati

onal

TW

G

mee

ting

s (P

ed,

Lepr

osy,

TB

/HIV

an

d M

DR-

TB,C

omm

unit

y an

d G

ende

r, co

re D

OTS

)

TWG

mee

ting

s he

ld20

TWG

mee

ting

s he

ld20

TWG

mee

ting

s he

ld20

TWG

mee

ting

s he

ld20

Num

ber m

onth

ly N

TLD

Pro

gram

sta

ff

mee

ting

s he

ld

Hol

d m

onth

ly N

TLD

Pro

gram

sta

ff m

eeti

ngs

12

NTL

D

Prog

ram

st

aff

mee

ting

s he

ld12

12

NTL

D

Prog

ram

st

aff

mee

ting

s he

ld12

12

NTL

D

Prog

ram

st

aff

mee

ting

s he

ld12

12

NTL

D

Prog

ram

st

aff

mee

ting

s he

ld12

Num

ber

of q

uart

erly

TB

Inte

r A

genc

y Co

rdin

atin

g Co

mm

itte

(T

B IC

C)

mee

ting

s he

ld

Hol

d qu

arte

rly

TB IC

C IC

C m

eeti

ngs

TB I

CC

mee

ting

s he

ld4

TB I

CC

mee

ting

s he

ld4

TB I

CC

mee

ting

s he

ld4

TB I

CC

mee

ting

s he

ld4

Prop

orti

on

of

coun

ties

co

nduc

ting

bi

annu

al

co

unty

le

vel

TB

inte

r ag

ency

cor

dina

tion

mee

ting

s

Supp

ort

bian

nual

co

unty

-lev

el

TB

inte

rage

ncy

coor

dina

ting

for

a H

old

bi

annu

al

coun

ty-l

evel

TB

in

tera

genc

y co

ordi

nati

ng f

ora

100%

Hol

d

bian

nual

co

unty

-le

vel

TB

inte

rage

ncy

coor

dina

ting

for

a

100%

Hol

d

bian

nual

co

unty

-le

vel

TB

inte

rage

ncy

coor

dina

ting

for

a

100%

Hol

d

bian

nual

co

unty

-le

vel

TB

inte

rage

ncy

coor

dina

ting

for

a

100%

Num

ber

of

ST

OP

TB

part

ners

hip

busi

ness

con

fere

nces

hel

dCo

nduc

t ST

OP

TB

Part

ners

hip

and

reso

urce

m

obili

zati

on c

onfe

renc

esCo

nduc

t ST

OP

TB P

artn

ersh

ip a

nd

reso

urce

mob

iliza

tion

con

fere

nce

1Co

nduc

t ST

OP

TB

Part

ners

hip

and

reso

urce

m

obili

zati

on c

onfe

renc

e

1Co

nduc

t ST

OP

TB

Part

ners

hip

and

reso

urce

m

obili

zati

on c

onfe

renc

e

1Co

nduc

t ST

OP

TB

Part

ners

hip

and

reso

urce

m

obili

zati

on c

onfe

renc

e

1

Prop

otio

n of

sc

hedu

led

TB

pe

rfor

man

ce r

evie

w m

eeti

ngs

held

Cond

uct

bian

nual

na

tion

al

perf

orm

ance

re

view

m

eeti

ngs

Bian

nual

na

tion

al

perf

orm

ance

re

view

mee

ting

s10

0%

100%

Bian

nual

na

tion

al

perf

orm

ance

re

view

m

eeti

ngs

100%

Bian

nual

na

tion

al

perf

orm

ance

re

view

m

eeti

ngs

100%

Prop

orti

on

of

sub

coun

ties

pa

rtic

ipat

ing

in

quar

terl

y re

view

m

eeti

ngs

Cond

uct

coun

ty-b

ased

qu

arte

rly

perf

orm

ance

re

view

mee

ting

sCo

nduc

t

coun

ty-b

ased

qu

arte

ly

perf

orm

ance

rev

iew

mee

ting

s10

0%Co

nduc

t

coun

ty-b

ased

qu

arte

ly

perf

orm

ance

re

view

mee

ting

s

100%

Cond

uct

co

unty

-bas

ed

quar

tely

pe

rfor

man

ce

revi

ew m

eeti

ngs

100%

Cond

uct

co

unty

-bas

ed

quar

tely

pe

rfor

man

ce

revi

ew m

eeti

ngs

100%

Num

ber

of

na

tion

al

TB

part

ner

revi

ew m

eeti

ngs

held

H

old

quar

terl

y na

tion

al p

artn

ers'

rev

iew

mee

ting

s to

alig

n in

terv

enti

ons

and

acti

viti

esH

old

quar

terl

y pa

rtne

rs

revi

ew

mee

ting

s 4

Hol

d qu

arte

rly

part

ners

re

view

mee

ting

s 4

Hol

d qu

arte

rly

part

ners

re

view

mee

ting

s 4

Hol

d qu

arte

rly

part

ners

re

view

mee

ting

s 4

1.4

Supp

orti

ve S

uper

visi

on

Num

ber

of v

ehic

les

proc

ured

Proc

ure

vehi

cle

tran

spor

t fo

r th

e N

TLD

Pro

gram

to

fa

cilit

ate

regu

lar

tech

nica

l as

sist

ance

to

th

e co

unti

es

n/a

Proc

ure

vehi

cles

4Pr

ocur

e ve

hicl

es4

n/a

4.3.2.1. Core DO

TS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on

of

the

NTL

D

Prog

ram

ve

hicl

es

wit

h no

do

wnt

ime

of

mor

e th

an 2

wee

ks d

ue t

o la

ck o

f m

aint

enan

ce

Mai

ntan

ance

of

NTL

D P

rogr

am m

otor

veh

icle

s Co

nduc

t sc

hedu

led

mai

ntai

nanc

e of

N

TLD

Pro

gram

veh

icle

s10

0%Co

nduc

t sc

hedu

led

mai

ntai

nanc

e of

N

TLD

Pr

ogra

m v

ehic

les

100%

Cond

uct

sche

dule

d m

aint

aina

nce

of

NTL

D

Prog

ram

veh

icle

s

100%

Cond

uct

sche

dule

d m

aint

aina

nce

of

NTL

D

Prog

ram

veh

icle

s

100%

Prop

orti

on o

f N

TLD

Pro

gram

veh

icle

s fi

tted

wit

h ne

w s

et o

f ti

res

annu

ally

Proc

ure

tyre

s fo

r N

TLD

Pro

gram

mot

or v

ehic

les

Proc

ure

44

mot

or

tyre

s fo

r N

TLD

Pr

ogra

m v

ehic

les

100%

Proc

ure

60 m

otor

ty

res

for

NTL

D P

rogr

am v

ehic

les

100%

Proc

ure7

6 m

otor

tyr

es f

or

NTL

D P

rogr

am v

ehic

les

100%

Proc

ure

76 m

otor

tyr

es f

or

NTL

D P

rogr

am v

ehic

les

100%

Prop

orti

on o

f N

TLD

Pro

gram

veh

icle

s w

ith

no d

ownt

ime

of m

ore

than

1 d

ay

due

to la

ck o

f fu

el

Proc

ure

fuel

for

NTL

D P

rogr

am v

ehic

les

Proc

ure

fuel

for

11

vehi

cles

100%

Proc

ure

fuel

for

11

vehi

cles

100%

Proc

ure

fuel

for

11

vehi

cles

100%

Proc

ure

fuel

for

11 v

ehic

les

100%

Prop

orti

on o

f cou

nty

vehi

cles

wit

h no

do

wnt

ime

of m

ore

than

2 w

eeks

due

to

lack

of

mai

nten

ance

Mai

ntan

ance

of

coun

ty -

base

d m

otor

veh

icle

sCo

nduc

t sc

hedu

led

mai

ntai

nace

of

10 c

ount

y-ba

sed

vehi

cles

100%

Cond

uct

sche

dule

d m

aint

aina

ce o

f 10

co

unty

-ba

sed

vehi

cles

100%

Cond

uct

sche

dule

d m

aint

aina

ce o

f 10

co

unty

-ba

sed

vehi

cles

100%

Cond

uct

sche

dule

d m

aint

aina

ce o

f 10

cou

nty-

base

d ve

hicl

es

100%

Prop

orti

on o

f co

unty

veh

icle

s fi

tted

w

ith

new

set

of

tire

s an

nual

lyPr

ocur

e ty

res

for

coun

ty-b

ased

mot

or v

ehic

les

Proc

ure

tyre

s fo

r 10

cou

nty-

base

d m

otor

veh

icle

s 10

0%Pr

ocur

e ty

res

for

10 c

ount

y-ba

sed

mot

or v

ehic

les

100%

Proc

ure

tyre

s fo

r 10

co

unty

-bas

ed

mot

or

vehi

cles

100%

Proc

ure

tyre

s fo

r 10

co

unty

-bas

ed

mot

or

vehi

cles

100%

Prop

orti

on o

f cou

nty

vehi

cles

wit

h no

do

wnt

ime

of m

ore

than

1 d

ay d

ue t

o la

ck o

f fu

el

Proc

ure

fuel

for

cou

nty-

base

d ve

hicl

esPr

ocur

e fu

el

for

10

coun

ty-b

ased

ve

hicl

es10

0%Pr

ocur

e fu

el f

or 1

0 co

unty

-ba

sed

vehi

cles

100%

Proc

ure

fuel

for

10

coun

ty-

base

d ve

hicl

es10

0%Pr

ocur

e fu

el f

or 1

0 co

unty

-ba

sed

vehi

cles

100%

Prop

orti

on

of

coun

ty

mot

orcy

cles

w

ith

no d

ownt

ime

of m

ore

than

1

wee

k du

e to

lack

of

mai

nten

ance

Mai

ntan

ance

of

coun

ty-b

ased

mot

orcy

cles

Mai

ntan

ance

of

150

coun

ty-b

ased

m

otor

cycl

es10

0%M

aint

anan

ce

of

150

coun

ty-b

ased

mot

orcy

cles

100%

Mai

ntan

ance

of

15

0 co

unty

-bas

ed m

otor

cycl

es10

0%M

aint

anan

ce

of

150

coun

ty-b

ased

mot

orcy

cles

100%

Prop

orti

on

of

coun

ty

mot

orcy

cles

fi

tted

wit

h ne

w s

et o

f ti

res

annu

ally

Proc

ure

tyre

s fo

r co

unty

-bas

ed m

otor

cyc

les

Proc

ure

300

tyre

s fo

r co

unty

-bas

ed

mot

or c

ycle

s 10

0%Pr

ocur

e 30

0 ty

res

for

coun

ty-b

ased

mot

or c

ycle

s 10

0%Pr

ocur

e 30

0 ty

res

for

coun

ty-b

ased

mot

or c

ycle

s 10

0%Pr

ocur

e 30

0 ty

res

for

coun

ty-b

ased

mot

or c

ycle

s 10

0%

Prop

orti

on

of

coun

ty

mot

orcy

cles

w

ith

no d

ownt

ime

of m

ore

than

1 d

ay

due

to la

ck o

f fu

el

Proc

ure

fuel

for

mot

orcy

cles

for

the

sub

-cou

ntie

s to

fa

cilit

ate

regu

lar

supp

ort

supe

rvis

ion

to

the

faci

litie

s

Proc

ure

fuel

for

150

cou

nty-

base

d m

otor

cycl

es10

0%Pr

ocur

e fu

el fo

r 150

cou

nty-

base

d m

otor

cycl

es10

0%Pr

ocur

e fu

el

for

150

coun

ty-b

ased

mot

orcy

cles

100%

Proc

ure

fuel

fo

r 15

0 co

unty

-bas

ed m

otor

cycl

es10

0%

Prop

orti

on

of

Sub

Coun

ty

TB

&

Lepr

osy

cord

inat

ors(

SC

TLC

s)

wit

h no

m

otor

cycl

es

rece

ivin

g m

onth

ly

reim

burs

emen

t fo

r pu

blic

tra

nspo

rt

Supp

ort

publ

ic t

rans

port

for

the

sub

-cou

ntie

s TB

co

rdin

ator

s (w

itho

ut

mot

or-c

ycle

s)

to

faci

litat

e re

gula

r su

ppor

t su

perv

isio

n to

the

TB

faci

litie

s

Supp

ort

publ

ic

tran

spor

t fo

r 15

0 su

b-co

unti

es

TB

cord

inat

ors

(wit

hout

mot

or-c

ycle

s) t

o fa

cilit

ate

regu

lar

supp

ort

supe

rvis

ion

to t

he

faci

litie

s

100%

Supp

ort

publ

ic

tran

spor

t fo

r 15

0 su

b-co

unti

es

TB

cord

inat

ors

(wit

hout

m

otor

-cyc

les)

to

fa

cilit

ate

regu

lar

supp

ort

supe

rvis

ion

to t

he f

acili

ties

100%

Supp

ort

publ

ic

tran

spor

t fo

r 15

0 su

b-co

unti

es

TB

cord

inat

ors

(wit

hout

m

otor

-cyc

les)

to

faci

litat

e re

gula

r su

ppor

t su

perv

isio

n to

the

fac

iliti

es

100%

Supp

ort

publ

ic

tran

spor

t fo

r 15

0 su

b-co

unti

es

TB

cord

inat

ors

(wit

hout

m

otor

-cyc

les)

to

faci

litat

e re

gula

r su

ppor

t su

perv

isio

n to

the

fac

iliti

es

100%

Prop

orti

on

of

NTL

D

Prog

ram

st

aff

prov

ided

w

ith

mon

thly

ai

rtim

e (in

clud

ing

driv

ers)

Prov

ide

mon

thly

ce

ll ph

one

airt

ime

for

NTL

D

Prog

ram

sta

ffPr

ovid

e ce

ll ph

one

airt

ime

for

44

NTL

D P

rogr

am s

taff

100%

Prov

ide

cell

phon

e ai

rtim

e fo

r 44

NTL

D P

rogr

am s

taff

100%

Prov

ide

cell

phon

e ai

rtim

e fo

r 44

NTL

D P

rogr

am s

taff

100%

Prov

ide

cell

phon

e ai

rtim

e fo

r 44

NTL

D s

taff

100%

Prop

orti

on

of

coun

ty

TB

staf

f pr

ovid

ed

wit

h m

onth

ly

airt

ime

(incl

udin

g dr

iver

s)

Prov

ide

mon

thly

cel

l pho

ne a

irti

me

for

CTL

Cs

Prov

ide

cell

phon

e ai

rtim

e fo

r 50

Co

unty

TB

& l

epro

sy c

oord

inat

ors

and

10 d

rive

rs

100%

Prov

ide

cell

phon

e ai

rtim

e fo

r 50

Cou

nty

TB &

lep

rosy

co

ordi

nato

rs a

nd 1

0 dr

iver

s

100%

Prov

ide

cell

phon

e ai

rtim

e fo

r 50

Cou

nty

TB &

lep

rosy

co

ordi

nato

rs a

nd 1

0 dr

iver

s

100%

Prov

ide

cell

phon

e ai

rtim

e fo

r 50

Cou

nty

TB &

lepr

osy

coor

dina

tors

and

10

driv

ers

100%

Prop

orti

on o

f C

TLC

s pr

ovid

ed w

ith

mon

thly

off

ice

stat

ione

ry s

uppo

rtPr

ovid

e C

TLC

s w

ith

mon

thly

off

ice

stat

iona

ryPr

ovid

e 50

C

TLC

s w

ith

mon

thly

of

fice

sta

tion

ary

100%

Prov

ide

50

CTL

Cs

wit

h m

onth

ly o

ffic

e st

atio

nary

100%

Prov

ide

50

CTL

Cs

wit

h m

onth

ly o

ffic

e st

atio

nary

100%

Prov

ide

50

CTL

Cs

wit

h m

onth

ly o

ffic

e st

atio

nary

100%

Prop

orti

on o

f SC

TLC

s p

rovi

ded

wit

h m

onth

ly a

irti

me

Pr

ovid

e S

CTL

Cs

wit

h m

onth

ly c

ell p

hone

air

tim

ePr

ovid

e 2

86 S

CTL

Cs

wit

h m

onth

ly

cell

phon

e ai

rtim

e10

0%Pr

ovid

e 2

86 S

CTL

Cs

wit

h m

onth

ly c

ell p

hone

air

tim

e10

0%Pr

ovid

e 2

86 S

CTL

Cs

wit

h m

onth

ly c

ell p

hone

air

tim

e10

0%Pr

ovid

e 2

86 S

CTL

Cs

wit

h m

onth

ly c

ell p

hone

air

tim

e10

0%

Prop

orti

on o

f SC

TLC

s pr

ovid

ed w

ith

mon

thly

off

ice

stat

ione

ry s

uppo

rtPr

ovid

e SC

TLC

s w

ith

mon

thly

off

ice

stat

iona

ryPr

ovid

e 28

6 SC

TLC

s w

ith

mon

thly

of

fice

sta

tion

ary

100%

Prov

ide

286

SCTL

Cs

wit

h m

onth

ly o

ffic

e st

atio

nary

100%

Prov

ide

286

SCTL

Cs

wit

h m

onth

ly o

ffic

e st

atio

nary

100%

Prov

ide

286

SCTL

Cs

wit

h m

onth

ly o

ffic

e st

atio

nary

100%

4.3.

2.1.

Cor

e D

OTS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on

of

nece

ssar

y an

d su

ffic

ient

off

ice

equi

pmen

t, s

uppl

ies

and

infr

astr

uctu

re

in

plac

e an

d in

go

od w

orki

ng o

rder

Proc

ure

offi

ce e

quip

men

t, s

uppl

ies

and

supp

ort

IT

mai

ntai

nanc

en/

a10

0%Pr

ocur

e 3

prin

ters

10

0%n/

a10

0%Pr

ocur

e 3

prin

ters

100%

Proc

ure

asso

rted

off

ice

supp

lies

for

the

NTL

D P

rogr

amPr

ocur

e as

sort

ed

offi

ce

supp

lies

for

the

NTL

D

Prog

ram

Proc

ure

asso

rted

of

fice

su

pplie

s fo

r th

e N

TLD

Pr

ogra

m

Proc

ure

asso

rted

of

fice

su

pplie

s fo

r th

e N

TLD

Pr

ogra

m

Supp

ort

IT m

aint

anan

ceSu

ppor

t IT

mai

ntan

ance

Supp

ort

IT m

aint

anan

ceSu

ppor

t IT

mai

ntan

ance

Supp

ort

purc

hase

of

la

ptop

co

mpu

ters

for

Cou

nty

TB &

Lep

rosy

Co

ordi

nato

rs

n/a

0%Pu

rcha

se

50

lapt

ops

for

CTL

Cs

100%

n/a

Purc

hase

50

la

ptop

s fo

r C

TLC

s

Prop

orti

on o

f C

TLC

s pr

ovid

ed w

ith

com

pute

rsSu

ppor

t Pu

rcha

se

of

Lapt

ops

for

Coun

ty

TB

&

Lepr

osy

Coor

dina

tors

n/a

0%Pu

rcha

se

50

lapt

ops

for

CTL

Cs

100%

n/a

Purc

hase

50

la

ptop

s fo

r C

TLC

s10

0%

Stra

tegi

c A

ppro

ach

2: T

arge

t A

ctiv

itie

s to

Incr

ease

Cas

e N

otif

icat

ion

Pack

age

1 C

NR

< 1

75/1

0000

0 Co

unti

es -

Vih

iga,

Lai

kipi

a, K

isii,

Kak

ameg

a, N

arok

, Tra

ns N

zoia

, Sam

buru

, Tan

a Ri

ver,

Bung

oma,

Nya

mir

a, W

ajir,

Elg

eyo

Mar

akw

et, N

yand

arua

, Bar

ingo

, Nan

di, M

ande

ra

Prop

orti

on

of

heal

th

faci

litie

s sc

reen

ing

coug

hers

for

TB

Cap

acit

y bu

ild H

CW

s to

dia

gnos

e an

d m

anag

e TB

10 T

B/H

IV t

rain

ings

50%

20 T

BHIV

tra

inin

gs60

%20

TBH

IV t

rain

ings

75%

10 T

B/H

IV t

rain

ings

100

Cond

uct

univ

ersa

l sc

reen

ing

for

TB o

f al

l co

ughe

rs

at a

ll cl

inic

al c

are

poi

nts

Scre

en

all

coug

hers

fo

r TB

at

al

l ou

tpat

ient

poi

nts

Scre

en a

ll co

ughe

rs f

or T

B at

all

outp

atie

nt p

oint

sSc

reen

all

coug

hers

for

TB

at a

ll ou

tpat

ient

poi

nts

Scre

en a

ll co

ughe

rs f

or T

B at

all

outp

atie

nt p

oint

s

Prop

orti

on

of

smea

r po

siti

ve

TB

pati

ents

who

se h

ouse

hold

con

tact

s w

ere

trac

ed a

nd s

cree

ned

for

TB

Cond

uct

cont

act

trac

ing

of

all

noti

fied

sm

ear

posi

tive

TB

pati

ents

n/a

Car

ry o

ut c

onta

ct t

raci

ng o

f al

l TB

pati

ents

60%

Car

ry o

ut c

onta

ct t

raci

ng

of a

ll TB

pat

ient

s80

%C

arry

out

con

tact

tra

cing

of

all

TB p

atie

nts

>80

%

Pack

age

2 C

NR

175-

250/

100,

000

Cou

ntie

s -

Embu

, Mac

hako

s, N

akur

u, K

iam

bu, N

yeri

, Mar

sabi

t, K

eric

ho, K

itui

, Mer

u, K

ajia

do, K

ilifi

, Mur

ang’

a, T

urka

na, T

aita

Tav

eta,

Gar

issa

, Lam

u, U

asin

Gis

hu, B

omet

, Bus

ia, M

akue

ni, W

est

Poko

t, K

wal

e

Num

ber

of

heal

th

care

w

orke

rs

trai

ned

on

TB

diag

nosi

s an

d m

anag

emen

t di

sagg

rega

ted

by c

adre

, ty

pe o

f tr

aini

ng a

nd c

ount

y

Cap

acit

y bu

ild H

CW

s to

dia

gnos

e an

d m

anag

e TB

11 T

B/H

IV t

rain

ings

275

22 T

B/H

IV t

rain

ings

550

22 T

B/H

IV t

rain

ings

550

11 T

B/H

IV t

rain

ings

275

Prop

orti

on

of

hous

ehol

d co

ntac

ts

of

noti

fied

TB

pa

tien

ts

trac

ed

and

scre

ened

for

TB

Car

ry o

ut c

onta

ct t

raci

ng o

f al

l TB

pati

ents

Car

ry o

ut c

onta

ct t

raci

ng o

f al

l TB

pa

tien

ts40

%C

arry

out

con

tact

tra

cing

of

all T

B pa

tien

ts50

%C

arry

out

con

tact

tra

cing

of

all

TB p

atie

nts

75%

Car

ry o

ut c

onta

ct t

raci

ng

of a

ll TB

pat

ient

s>

80%

Pack

age

3 C

NR

> 2

50/1

00,0

00 C

ount

ies

- M

omba

sa, N

airo

bi, H

oma

Bay,

Kis

umu,

Isio

lo, M

igor

i, Si

aya,

Tha

raka

, Kir

inya

ga

4.3.2.1. Core DO

TS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on o

f TB

pat

ient

s in

tar

get

coun

ties

pr

ovid

ed

wit

h nu

trit

iona

l su

ppor

t

Stre

ngth

enin

g ac

cess

to

soci

al p

rote

ctio

n A

ctiv

itie

s co

vere

d un

der

soci

al

prot

ecti

onA

ctiv

itie

s co

vere

d un

der

soci

al p

rote

ctio

nA

ctiv

itie

s co

vere

d un

der

soci

al p

rote

ctio

nA

ctiv

itie

s co

vere

d un

der

soci

al p

rote

ctio

n

Perc

enta

ge o

f cou

ntie

s w

ith

effe

ctiv

e sp

utum

ref

erra

l net

wor

ksSt

reng

then

ing

sput

um s

ampl

e re

ferr

al n

etw

orks

Act

ivit

ies

cove

red

un

der

acce

lera

tion

of

appr

oria

te d

iagn

osis

Act

ivit

ies

cove

red

un

der

acce

lera

tion

of

ap

pror

iate

di

agno

sis

Act

ivit

ies

cove

red

un

der

acce

lera

tion

of

appr

oria

te

diag

nosi

s

Act

ivit

ies

cove

red

und

er

acce

lera

tion

of

appr

oria

te

diag

nosi

s

Stra

tegi

c A

ppro

ach

3: E

xpan

d sp

ecia

l ini

tiat

ives

to

reac

h m

ost

a ri

sk p

opul

atio

ns

Prop

orti

on o

f tr

aine

d he

alth

fac

iliti

es

scre

enin

g fo

r TB

in d

iabe

tic

clin

ics

Syst

emat

ic

scre

enin

g fo

r TB

in

pa

tien

ts

wit

h di

abet

es a

nd in

oth

er c

linic

al s

etti

ngs

0Se

nsit

ize

he

alth

care

w

orke

rs

from

2

faci

litie

s pe

r co

unty

in

16 c

ount

ies

to i

niti

ate

scre

enin

g fo

r TB

(D

M c

linic

s, M

CH

, in-

pati

ent

and

outp

atie

nt)

100%

Sens

itiz

e

heal

thca

re

wor

kers

fr

om

2 fa

cilit

ies

per

coun

ty i

n 16

cou

ntie

s to

in

itia

te

scre

enin

g fo

r TB

(D

M

clin

ics,

M

CH

, in

-pa

tien

t an

d ou

tpat

ient

)

100%

Sens

itiz

e

heal

thca

re

wor

kers

fr

om

2 fa

cilit

ies

per

coun

ty i

n 16

cou

ntie

s to

in

itia

te

scre

enin

g fo

r TB

(D

M

clin

ics,

M

CH

, in

-pa

tien

t an

d ou

tpat

ient

)

100%

Num

ber

of p

riso

n w

arde

ns t

rain

edPr

int

TB s

cree

ning

too

ls f

or p

riso

nsPr

int

boo

klet

s fo

r TB

scr

eeni

ng i

n pr

ison

s1,

500

Prin

t

book

lets

fo

r TB

sc

reen

ing

in p

riso

ns1,

500

00

Trai

n 48

0 pr

ison

w

arde

ns

on

a co

mpr

ehen

sive

se

rvic

e de

liver

y pa

ckag

e (T

B sc

reen

ing

upon

ent

ry

to p

riso

ns,p

rovi

ding

hea

lth

educ

atio

n an

d D

OT

to

inm

ates

)

Cond

uct

4 tr

aini

ng

for

pris

on

war

dens

120

Cond

uct

4 tr

aini

ng

for

pris

on w

arde

ns12

0Co

nduc

t 4

trai

ning

fo

r pr

ison

war

dens

120

Cond

uct

4 tr

aini

ng

for

pris

on w

arde

ns12

0

Num

ber

of p

riso

ns w

ith

TB IP

C p

lans

Enha

nce

TB i

nfec

tion

con

trol

pra

ctic

es in

pri

sons

0Co

nduc

t 15

TB

IPC

tra

inin

g ta

rget

ting

pri

son

staf

f15

015

Cond

uct

5 TB

IPC

tra

inin

g ta

rget

ting

pri

son

staf

f5

0Co

nduc

t TB

in

fect

ion

risk

as

sesm

ent

in 1

5 pr

ison

s0

Cond

uct

TB i

nfec

tion

ris

k as

sesm

ent

in 5

pri

sons

00

Dev

elop

TB

IPC

pla

ns fo

r 15

pr

ison

sD

evel

op T

B IP

C p

lans

for

5

pris

ons

Num

ber

of

pris

ons

prov

idin

g TB

m

anag

emen

t as

pe

r na

tion

al

guid

elin

es

Dev

elop

TB

heal

th e

duca

tion

too

ls f

or p

riso

ners

an

d pr

ison

sta

ff i

nclu

ding

su

ppor

ting

the

rev

iew

of

TB

cont

ent

in t

he r

ecru

it t

rain

ing

curr

icul

um a

t th

e K

PS T

rain

ing

Colle

ge a

nd r

evie

w a

nd u

pdat

e th

e PF

10.

0Co

nduc

t a

wor

ksho

p to

de

velo

p he

alth

ed

ucat

ion

tool

s fo

r pr

ison

ers

and

pris

on s

taff

15Co

nduc

t a

wor

ksho

p to

in

trod

uce

heal

th e

duca

tion

to

ols

for

pris

oner

s an

d pr

ison

sta

ff

15Co

nduc

t a

wor

ksho

p to

de

velo

p he

alth

ed

ucat

ion

tool

s fo

r pr

ison

ers

and

pris

on s

taff

20

1. N

umbe

r of

pri

sons

pro

vide

d w

ith

light

mic

rosc

opes

2.

Num

ber

of

pris

ons

wit

h X

pert

m

achi

nes

Proc

ure

and

inst

all

15 l

ight

mic

rosc

opes

and

3

Xpe

rt M

TB/R

IF f

or p

riso

n he

alth

ser

vice

sCo

vere

d un

der

acce

lera

ting

ap

pror

iate

dia

gnos

isPr

ocur

e an

d in

stal

l 15

ligh

t m

icro

scop

es

and

3 X

pert

M

TB/R

IF

for

pris

on

heal

th

serv

ices

1. 1

5

2

1. N

umbe

r of

hea

lth

care

wor

kers

in

pri

sons

tra

ined

on

use

of X

pert

m

achi

ne

2. N

umbe

r of

hea

lth

care

wor

kers

in

GoK

pri

sons

tra

ined

on

DO

Ts

Ensu

re

on-s

ite

diag

nost

ic

and

DO

T ca

paci

ty

in

pris

ons

Dev

elop

sc

reen

ing

algo

rith

m

for

pris

ons;

pro

vide

sen

siti

zati

onn/

aTr

aini

ng o

f H

CW

s in

pri

sons

on

DO

TS a

nd X

pert

9In

trod

uce

an

nual

TB

sc

reen

ing

as

part

of

ro

utin

e/pe

riod

ic

wel

lnes

s ex

amin

atio

n fo

r pr

ison

st

aff

40%

Intr

oduc

e

annu

al

TB

scre

enin

g as

pa

rt

of

rout

ine/

peri

odic

w

elln

ess

exam

inat

ion

for

pris

on

staf

f

50%

4.3.

2.1.

Cor

e D

OTS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Num

ber

of

cent

ers

of

exce

llenc

e es

tabl

ishe

d Es

tabl

ish

Cen

ters

of

Ex

celle

nce

(CoE

) fo

r m

anag

emen

t of

TB

,TB/

HIV

,MD

R-TB

an

d Lu

ng

Dis

ease

in N

airo

bi, M

omba

sa, K

isum

u, H

oma

Bay

&

Gar

issa

(ref

ugee

s/D

aada

b) c

ount

ies

Iden

tify

CoE

0Bu

ild c

apac

ity

staf

f at

the

si

te f

or C

oE f

unct

ion

3Bu

ild c

apac

ity

staf

f at

the

si

te f

or C

oE f

unct

ion

5Bu

ild c

apac

ity

staf

f at

the

si

te f

or C

oE f

unct

ion

5

Cap

acit

y bu

ildin

g of

HC

Ws

to d

iagn

ose

and

man

age

TB5

TB/H

IV t

rain

ings

9 TB

/HIV

tra

inin

gs9

TB/H

IV t

rain

ings

9 TB

/HIV

tra

inin

gs

Cap

acit

y bu

ildin

g of

lab

staf

f to

dia

gnos

e TB

Act

ivit

ies

cove

red

un

der

acce

lera

tion

of

appr

oria

te d

iagn

osis

Act

ivit

ies

cove

red

un

der

acce

lera

tion

of

ap

pror

iate

di

agno

sis

Act

ivit

ies

cove

red

un

der

acce

lera

tion

of

appr

oria

te

diag

nosi

s

Act

ivit

ies

cove

red

und

er

acce

lera

tion

of

appr

oria

te

diag

nosi

s

Prop

orti

on

of

hous

ehol

d co

ntac

ts

of

noti

fied

TB

pa

tien

ts

trac

ed

and

scre

ened

for

TB

Car

ry o

ut c

onta

ct t

raci

ng o

f al

l TB

pati

ents

C

arry

out

con

tact

tra

cing

of

all

TB

pati

ents

Car

ry o

ut c

onta

ct t

raci

ng o

f al

l TB

pati

ents

Car

ry o

ut c

onta

ct t

raci

ng

of a

ll TB

pat

ient

sC

arry

out

con

tact

tra

cing

of

all

TB p

atie

nts

Num

ber

of

dire

ctor

ies

of

info

rmal

he

alth

ca

re

prov

ider

s in

N

airo

bi,

Kis

umu

and

Mom

basa

ci

ties

de

velo

ped

Map

out

inf

orm

al h

ealt

h ca

re p

rovi

ders

, ch

emis

ts

and

pham

acis

ts in

urb

an s

lum

s in

Nai

robi

, Mom

basa

an

d K

isum

u ci

ties

Cond

uct

map

ping

of

urba

n sl

ums

in

Nai

robi

, K

isum

u (K

isum

u), M

omba

sa

Num

ber

of

CH

EWs

cove

ring

urb

an

slum

s tr

aine

d on

in

tens

ive

case

fi

ndin

g

Trai

n co

mm

unit

y he

alth

ex

tens

ion

wor

kers

co

veri

ng u

rban

slu

ms

on i

nten

sifi

ed c

ase

find

ing

tool

s

0Tr

ain

50

per

coun

ty

for

Nai

robi

, Kis

umu,

Mom

basa

150

Trai

n 50

pe

r co

unty

fo

r N

akur

u,

Uas

in

Gis

hu,

Kia

mbu

, Em

bu C

HEW

s

200

0

Perc

enta

ge

of

map

ped

in

form

al

heal

th

prov

ider

s co

nduc

ting

ac

tive

C

ase

find

ing

in u

rban

slu

ms

Inco

rpor

ate

the

info

rmal

he

alth

ca

re

prov

ider

s,

chem

ists

and

pha

rmac

ies

in a

ctiv

e TB

cas

e fi

ndin

g in

terv

enti

ons

in lo

w-i

ncom

e ur

ban

sett

lem

ents

0In

corp

orat

e ph

arm

acis

ts,

chem

ists

an

d in

form

al

heal

th c

are

prov

ider

s f

or

104

days

pe

r an

num

pe

r co

unty

by

50

C

HEW

s pe

r co

unty

20%

Inco

rpor

ate

phar

mac

ists

, ch

emis

ts

and

info

rmal

he

alth

car

e pr

ovid

ers

for

10

4 da

ys

per

annu

m

per

coun

ty b

y 50

CH

EWs

per

coun

ty

40%

Inco

rpor

ate

phar

mac

ists

, ch

emis

ts

and

info

rmal

he

alth

car

e pr

ovid

ers

for

10

4 da

ys

per

annu

m

per

coun

ty b

y 50

CH

EWs

per

coun

ty

>60

%

Prop

orti

on

of

trai

ned

CH

EWs

part

icip

atin

g in

qu

arte

rly

feed

back

m

eeti

ngs

Hol

d qu

arte

rly

feed

back

for

ums

for

the

CH

EWs

invo

lved

in T

B ca

se f

indi

ng in

urb

an s

lum

s0

Cond

uct

quar

terl

y fe

edba

ck

mee

ting

s fo

r C

HEW

S in

N

airo

bi, K

isum

u, M

omba

sa

100%

Cond

uct

quar

terl

y fe

edba

ck

mee

ting

s in

N

airo

bi, K

isum

u, M

omba

sa,

Kia

mbu

(T

hika

), N

akur

u,

Uas

in G

ishu

(Eld

oret

), Em

bu

100%

Cond

uct

quar

terl

y fe

edba

ck

mee

ting

s in

N

airo

bi, K

isum

u, M

omba

sa,

Kia

mbu

(T

hika

), N

akur

u,

Uas

in

Gis

hu

(Eld

oret

), Em

bu

100%

Pack

age

4 Tr

eatm

ent

Succ

ess

Rate

< 8

8% C

ount

ies

- N

airo

bi, H

oma

Bay,

Kis

umu,

Isio

lo, S

iaya

, Kir

inya

ga, M

acha

kos,

Nak

uru,

Kia

mbu

, Nye

ri, K

itui

, Mer

u, T

aita

Tav

eta,

Bus

ia, L

aiki

pia,

Kis

ii, S

ambu

ru, T

ana

Rive

r, Bu

ngom

a, E

lgey

o M

arak

wet

, Nya

ndar

ua, B

arin

go, N

andi

Prop

orti

on o

f de

faul

ters

tra

ced

and

retu

rned

to

care

Car

ry o

ut d

efau

lter

tra

cing

of

TB p

atie

nts

Car

ry o

ut d

efau

lter

tra

cing

of

5,00

0 TB

pat

ient

s60

%C

arry

out

def

ault

er t

raci

ng

of 5

,000

TB

pati

ents

>80

%C

arry

out

def

ault

er t

raci

ng

of 5

,000

TB

pati

ents

>80

%C

arry

out

def

ault

er t

raci

ng

of 5

,000

TB

pati

ents

>80

%

Stre

ngth

en a

cces

s to

cri

tica

l ena

bler

sW

eeky

SM

Ss t

o al

l pa

tien

ts

as

rem

inde

rs

of

clin

ic

appo

intm

ents

Wee

ky S

MSs

to

all p

atie

nts

as

rem

inde

rs

of

clin

ic

appo

intm

ents

Wee

ky S

MSs

to

all p

atie

nts

as

rem

inde

rs

of

clin

ic

appo

intm

ents

Impr

ove

heal

th e

duca

tion

Wee

ky

SMSs

to

pa

tien

ts

on e

xpec

ted

Aes

and

oth

er

heal

th e

duca

tion

mes

sage

s

Wee

ky

SMSs

to

pa

tien

ts

on e

xpec

ted

Aes

and

oth

er

heal

th e

duca

tion

mes

sage

s

Wee

ky

SMSs

to

pa

tien

ts

on e

xpec

ted

Aes

and

oth

er

heal

th e

duca

tion

mes

sage

s

Build

CH

EW c

apac

ity

to o

vers

ee f

amily

-bas

ed &

co

mm

unit

y su

ppor

ted

DO

TA

ctiv

itie

s co

vere

d un

der

com

mun

ity

enga

gem

ent

Act

ivit

ies

cove

red

unde

r co

mm

unit

y en

gage

men

t A

ctiv

itie

s co

vere

d un

der

com

mun

ity

enga

gem

ent

Pack

age

5 Po

vert

y Pr

eval

ence

> 4

5% C

ount

ies

- Bar

ingo

, Bom

et, B

ungo

ma,

Bus

ia, G

aris

sa, I

siol

o, K

akam

ega,

Elg

eyo

Mar

akw

et, K

ilifi

, Kis

ii, K

itui

, Kw

ale,

Lai

kipi

a, M

acha

kos,

Mak

ueni

, Man

dera

, Mar

sabi

t, N

andi

, Nya

ndar

ua, S

ambu

ru, T

aita

Tav

eta,

Tan

a Ri

ver,

Tran

s N

zoia

, Tur

kana

, Waj

ir, W

est

Poko

t

4.3.2.1. Core DO

TS

Core

DO

TS O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Num

ber

of p

riso

ns w

ith

docu

men

ted

refe

rral

fo

r pa

tien

ts

rele

ased

or

tr

ansf

erre

d

Dev

elop

ref

erra

l mec

hani

sms

for

pris

oner

s w

ho a

re

tran

sfer

red

or r

elea

sed

0H

old

two

day

cons

ulta

tive

m

eeti

ng t

o de

velo

p re

ferr

al

mec

hani

sms

for

pris

oner

s

15Se

nsit

ize

HC

Ws

in p

riso

ns

and

rece

ivin

g fa

cilit

ies

abou

t re

ferr

als

for

pris

oner

s

15Se

nsit

ize

HC

Ws

in p

riso

ns

and

rece

ivin

g fa

cilit

ies

abou

t re

ferr

als

for

pris

oner

s

15

Prop

orti

on

of

GoK

pr

ison

st

aff

scre

ened

for

TB

annu

ally

Intr

oduc

e a

nnua

l TB

scr

eeni

ng a

s pa

rt o

f ro

utin

e/pe

riod

ic w

elln

ess

exam

inat

ion

for

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on s

taff

Dev

elop

sc

reen

ing

algo

rith

m

for

pris

ons

and

cond

uct

sens

itiz

atio

nn/

aPe

rfor

m

an

nual

TB

sc

reen

ing

as

part

of

ro

utin

e/pe

riod

ic

wel

lnes

s ex

amin

atio

n fo

r pr

ison

sta

ff

25%

Perf

orm

annu

al

TB

scre

enin

g as

pa

rt

of

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ine/

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odic

w

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ess

exam

inat

ion

for

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on

staf

f

40%

Perf

orm

annu

al

TB

scre

enin

g as

pa

rt

of

rout

ine/

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odic

w

elln

ess

exam

inat

ion

for

pris

on

staf

f

50%

Num

ber

of

labo

rato

ry

tech

nolo

gist

s hi

red

and

retr

aine

d fo

r pr

ison

hea

lth

serv

ices

Recr

uit

15 l

abor

ator

y te

chno

logi

sts

for

pris

on h

ealt

h se

rvic

es0

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Re

cr

ui

t an

d de

ploy

la

bo

rato

ry

tech

no

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sts

for

pris

on

he

al

th

serv

ices

15T

ra

in

lab

ora

to

ry

tech

no

log

ists

fo

r pr

ison

he

alth

ser

vice

s

15t

ra

in

lab

or

at

or

y te

chn

olo

gis

ts

for

pris

on

heal

th s

ervi

ces

Prop

orti

on

of

heal

th

faci

litie

s pr

ovid

ing

TB

man

agem

ent

serv

ices

w

ith

TB IP

C p

lans

Impl

emen

t TB

in

fect

ion

cont

rol

in

all

heal

th

faci

litie

sCo

vere

d un

der

TB/H

IV a

ctiv

itie

sn/

a0

n/a

0n/

a0

n/a

Perc

enta

ge

of

ti

ers

2,3

heal

th

faci

litie

s co

nduc

ting

annu

al

scre

enin

g of

HC

W f

or T

B

Dis

sem

inat

e re

vise

d TB

w

orkp

ace

polic

y th

at

reco

mm

ends

rou

tine

ann

ual s

cree

ning

of

HC

Ws

Cove

red

unde

r TB

/HIV

act

ivit

ies

Cove

red

unde

r TB

/HIV

ac

tivi

ties

25%

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red

unde

r TB

/HIV

ac

tivi

ties

50%

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red

unde

r TB

/HIV

ac

tivi

ties

>50

%

Cond

uct

annu

al T

B s

cree

ning

for

HC

Ws

as p

art

of a

re

vise

d w

orkp

lace

-bas

ed p

olic

y on

TB

cont

rol

n/a

Cond

uct

an

nual

TB

sc

reen

ing

for a

ll H

CW

s in

all

tier

5 a

nd 6

hea

lth

faci

litie

s

Cond

uct

annu

al

TB

scre

enin

g fo

r al

l H

CW

s in

ti

ers

4,5

and

6 he

alth

fa

cilit

ies

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uct

annu

al

TB

scre

enin

g fo

r al

l H

CW

s in

ti

er

4,5

and

6 he

alth

fa

cilit

ies

Num

ber

of

heal

th

care

w

orke

rs

serv

ing

mob

ile

popu

lati

ons

trai

ned

on T

B/H

IV in

tegr

atio

n

Inte

grat

e TB

ser

vice

s in

the

alr

eady

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stin

g H

IV

serv

ices

for

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ile a

nd m

igra

nt p

opul

atio

nsn/

aTr

ain

he

alth

st

aff

from

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IV c

linic

s se

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g m

obile

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pula

tion

s on

TB

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HIV

an

d in

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atio

n of

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vice

s

150

Trai

n

heal

th

staf

f fr

om

HIV

clin

ics

serv

ing

mob

ile

popu

lati

ons

on

TB,T

B/H

IV

and

inte

grat

ion

of s

ervi

ces

150

n/a

0

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orti

on o

f do

cum

ente

d co

ntac

ts

of i

ndex

TB

pati

ents

not

ifie

d am

ong

mob

ile p

opul

atio

ns w

ho a

re t

race

d by

pho

ne

Cond

uct c

ell-

phon

e tr

acin

g fo

r all

cont

acts

of i

ndex

TB

pat

ient

s no

tifi

ed a

mon

g m

obile

pop

ulat

ions

n/a

Cond

uct

cell-

phon

e t

raci

ng

for

all

cont

acts

of

inde

x TB

pa

tien

ts

noti

fied

am

ong

mob

ile p

opul

atio

ns

100%

Cond

uct

cell-

phon

e tr

acin

g fo

r al

l co

ntac

ts o

f in

dex

TB p

atie

nts

noti

fied

am

ong

mob

ile p

opul

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ns

100%

Cond

uct

cell-

phon

e tr

acin

g fo

r al

l co

ntac

ts o

f in

dex

TB p

atie

nts

noti

fied

am

ong

mob

ile p

opul

atio

ns

100%

Num

ber

of h

ealt

h ca

re w

orke

rs f

rom

un

ifor

med

ser

vice

s tr

aine

d on

TB/

HIV

in

tegr

atio

n

Supp

ort

inte

grat

ion

of

TB

serv

ices

in

al

read

y ex

isti

ng H

IV s

ervi

ces

to s

uppo

rt c

ase

find

ing

, cas

e ho

ldin

g an

d im

prov

e up

take

of

inte

rven

tion

s fo

r th

e co

-inf

ecte

d

Trai

n 12

0 he

alth

sta

ff o

n TB

,TB/

HIV

an

d in

tegr

atio

n of

ser

vice

s12

0Tr

ain

120

heal

th

staf

f on

TB

,TB/

HIV

an

d in

tegr

atio

n of

ser

vice

s

120

Trai

n 12

0 he

alth

sta

ff o

n TB

,TB/

HIV

and

int

egra

tion

of

ser

vice

s

120

Trai

n 12

0 he

alth

sta

ff o

n TB

,TB/

HIV

and

int

egra

tion

of

ser

vice

s

120

Prop

orti

on o

f do

cum

ente

d co

ntac

ts

of

inde

x TB

pa

tien

ts

noti

fied

by

un

ifor

m s

ervi

ce p

erso

nnel

who

are

tr

aced

and

scr

eene

d fo

r TB

Cond

uct

acti

ve t

raci

ng f

or a

ll co

ntac

ts o

f in

dex

TB

pati

ents

not

ifie

d by

uni

form

ed s

ervi

ce p

erso

nell

heal

th s

ervi

ces

n/a

Cond

uct

acti

ve

tr

acin

g fo

r al

l co

ntac

ts

of

inde

x TB

pa

tien

ts

noti

fied

by

un

ifor

med

ser

vice

per

sone

ll he

alth

ser

vice

s

50%

Cond

uct

acti

ve

tr

acin

g fo

r al

l co

ntac

ts

of

inde

x TB

pa

tien

ts

noti

fied

by

un

ifor

med

se

rvic

e pe

rson

ell h

ealt

h se

rvic

es

>80

%Co

nduc

t ac

tive

trac

ing

for

all

cont

acts

of

in

dex

TB

pati

ents

no

tifi

ed

by

unif

orm

ed

serv

ice

pers

onel

l hea

lth

serv

ices

>80

%

Prop

orti

on o

f G

oK u

nifo

rmed

ser

vice

pe

rson

nel s

cree

ned

for

TB a

nnua

llyIn

trod

uce

ann

ual

TB s

cree

ning

as

part

of

rout

ine/

peri

odic

w

elln

ess

exam

inat

ion

for

un

ifor

med

se

rvic

e pe

rson

ell

Perf

orm

an

nual

TB

sc

reen

ing

as

part

of

ro

utin

e/pe

riod

ic

wel

lnes

s ex

amin

atio

n fo

r un

ifor

med

se

rvic

e pe

rson

ell

50%

Intr

oduc

e

annu

al

TB

scre

enin

g as

pa

rt

of

rout

ine/

peri

odic

w

elln

ess

exam

inat

ion

for

unif

orm

ed

serv

ice

pers

onel

l

70%

Intr

oduc

e

annu

al

TB

scre

enin

g as

pa

rt

of

rout

ine/

peri

odic

w

elln

ess

exam

inat

ion

for

unif

orm

ed

serv

ice

pers

onel

l

70%

1. N

umbe

r of

hea

lth

care

wor

kers

at

refu

gee

cam

ps t

rain

ed o

n in

fect

ion

cont

rol

2. N

umbe

r of

ref

ugee

cam

ps w

ith

IPC

pl

ans

Enha

nce

infe

ctio

n co

ntro

l ca

paci

ty w

ithi

n re

fuge

e ca

mps

Cove

red

unde

r TB

HIV

an

d dr

ug

resi

stan

t TB

Cove

red

unde

r TB

HIV

an

d dr

ug r

esis

tant

TB

0Co

vere

d un

der

TB/H

IV a

nd

drug

res

ista

nt T

B0

n/a

4.3.

2.1.

Cor

e D

OTS

4.3.2.2. Programmatic Management of Drug Resistant TB1. Situational Analysis

Kenya notified 254 cases of MDR-TB in 2013, 28% of who were refugees from neighboring Somalia. The number of MDR-TB cases detected in Kenya has risen steadily since 2010, when only 112 cases were detected. World Health Organization estimates that there were 1,800 new MDR-TB cases in Kenya in 2012. A drug-resistance survey is underway to determine a more precise DR-TB estimate. With GeneXpert rollout, it is expected that the number of MDR-TB cases detected will increase dramatically.

In 2013, there were 226 MDR-TB treatment sites for the 254 newly registered MDR-TB patients across the country. The treatment success rate for the 135 MDR-TB cases notified in 2011 was 68%. The country revised the Programmatic Management of Drug Resistant TB (PMDT) guidelines in 2013. A national MDR-TB focal person provides technical assistance to the counties, and is supported by a national MDR-TB committee. At county level, county tuberculosis and leprosy coordinators are responsible for linkage of MDR-TB patients to care, treatment initiation and follow-up. The country largely uses ambulatory and community – based models of care. The country has 114 hospital-bed capacity to manage MDR−TB patients spread across the following four sites: Kenyatta National Hospital (15 beds), MTRH (8 beds), Homa Bay (11 beds) and Dadaab (80 beds). DOT is provided at selected health facilities networked to community health workers who treat patients in the community.

MDR-TB patients receive KSH 6000 (approx. US$ 75) per month for their transport costs to health care facilities and nutritional support if needed.

Figure 13: Number of Notified MDR-TB Cases by County, 2013

4.3.2.2. Programm

atic Managem

ent of Drug Resistant TB

Map 3: Number of Notified MDR-TB Cases and Overall Case Notification Rate by County, 2013

38

4.3.

2.2.

Pro

gram

mat

ic M

anag

emen

t of D

rug

Resi

stan

t TB

Case finding strategies are in accordance with WHO recommendations, including DR-TB surveillance among the populations most at risk, especially retreatment cases and refugees. The treatment regimens are also in line with WHO recommendations using WHO pre–qualified, quality assured second line drugs. The current treatment regimen is administered for a total of 20 months; Intensive phase of at least 8 months of Kanamycin, Levofloxacin, Cycloserine, prothionamide and pyrazinamide, and continuation phase of 12 months of Levofloxacin, Cycloserine, Prothionamide and Pyrazinamide.

Some of the drugs to manage side effects are also available free-of-charge at the treatment sites, while adverse drug events are reported using a pharmacovigilance platform provided by the Pharmacy and Poisons Board. DST for first-line drugs is done at NTRL, and second-line drugs (Kanamycin, Capreomycin and Ofloxacin) outside the country. There is an external quality assurance program for the NTRL provided by a supra-national laboratory.

2. Strategic Directions for 2015-2018

Priorities for the three-year period are geared towards increasing the case notification of DR-TB to at least 75% of estimated prevalence by 2017, and attaining a treatment success rate of at least 80% among all cases of DR TB by 2017. The NTLD Program is committed to ensuring that human rights principles are taken into account as the PMDT strategies are implemented.

These strategies include:

a) Strengthening systems that support PMDTb) Systematic surveillance of DR-TB, including childrenc) Reducing time to diagnosis of DR-TBd) Ensuring timely initiation of treatment (within 1-2 weeks of diagnosis)e) Improve monitoring and evaluation of presumptive and confirmed DR-TB casesf) Improve treatment outcomes for DR-TB patients, including children.

3. Proposed Approaches

Strengthening Systems that Support PMDT

The NTLD Program will continue offering oversight in the implementation of PMDT services in the country through the PMDT focal person, with the support of a national Technical Working Group meeting quarterly.

With extensive decentralization of PMDT services across the country, strengthening the quality of clinical care is imperative. As such, PMDT teams shall be established at each level of care to monitor patient management. The county PMDT committees will offer oversight and support for the sub-county teams. The sub-county TWGs will conduct mentorship and monthly patient reviews at a central site (sub-county or county hospital). The formation of sub-county TWGs will be targeted to sub counties with existing DR-TB patients.

Figure 14: DR-TB Case Notification Trends 2008-2013

39

Admission facilities shall be expanded across the country for DR-TB patients. The GLC review conducted during the MTR advised that each county have at least 4 beds for admission with appropriate infection control measures in place.

Development and dissemination of a tool for assessment of social security needs (i.e. nutrition & other social support) will be done as part of social protection for DR-TB patients. Promotion of availability of nutritional and other social support for eligible DR-TB patients on ambulatory and community-based models of care will also be done.

An interagency/inter-ministerial team to address the problem of cross border DR-TB will be set up and meetings will be held biannually.

The checklist for supervisory/support visits shall be updated to adequately cover DR-TB.

Strengthening Systematic Surveillance of DR-TB

To enhance surveillance of DR-TB, the country shall strive to improve the capacity of HCWs through sensitization, mentorship and training on DR-TB surveillance including the use of GeneXpert technology.

The NTLD Program shall disseminate and aggressively encourage the use of the updated GeneXpert diagnostic algorithm across all service delivery points. These guidelines shall be updated as often as possible to keep pace with the emerging evidence on Xpert use even in non-sputum specimens. In collaboration with the lab program, all the existing and new Xpert machines in the counties shall be networked while taking advantage of other existing and innovative strategies to improve sample referrals e.g. appending Xpert samples transport to the CD4 and viral load transport network in the HIV system and use of other locally available means of transport. These strategies shall go hand in hand with the plans to ensure there are 250 GeneXpert machines in the country by end of 2017. They shall be rationally distributed considering factors like TB burden, accessibility and existing machines.

New strategies to expand DR-TB surveillance in congregate settings (schools, prisons, HCWs, migrant populations, public transport - matatus through their associations) will be explored. In addition to ensuring that all TB retreatment cases access Xpert tests at start of TB therapy, special emphasis has been put on the use of Xpert as first line of testing among PLHIV and the pediatric age group.

Active contact tracing of all children exposed to DR-TB shall be logistically supported and quarterly screening of all DR-TB contacts done for up to a period of 2 years post culture conversion of the index DR-TB case. All symptomatic contacts of DR-TB (including children) will be prioritized to benefit from Xpert testing. More awareness in the community and congregate settings on DR-TB shall be carried out while at the same time strengthening systems to ensure early referrals among presumptive DR-TB cases.

The NTRL shall be encouraged to invest in second line DST for all MDR-TB patients systematically prior to treatment initiation to identify XDR-TB early enough to impact morbidity and mortality.

Reduction of time to diagnosis of DR-TB

GeneXpert test will be the first diagnostic tool for all presumptive DR-TB cases. Once the samples are networked to the GeneXpert laboratories, results shall be dispatched electronically as soon as they are run, and no later than 24-48 hours. Electronic real time result dispatch software shall be installed in all GeneXpert machines.

The system shall be used for automatic results transmissions to ordering clinicians, patients and the programs. How fast Xpert (and culture and DST) results are relayed back, received and acted on shall be actively monitored to improve the programs. Timely GeneXpert equipment servicing and secondary networking of new Xpert sites will also be done to reduce downtime of machines. For culture and DST results, a link will also be created between LIMS and TIBU to ensure timely dissemination of results.

Ensure timely initiation of treatment (within 1-2 weeks of diagnosis)

DR-TB patients will be registered immediately at diagnosis, baseline investigations (FBC, UECs, LFTs, TSH) done within 1-2 days of diagnosis and results dispatched electronically. The baseline investigations (including chest radiographs and audiometry) will be standardized and made free for the patients with the support of USAID and Global Fund.

The target is to ensure each county has a functional, portable and accessible audiometer machine for DR-TB patients by 2017. Structured clinical teams (DR-TB/HIV multidisciplinary teams) shall be set up and used to initiate and follow up treatment. The composition of such teams shall, at a minimum, have the sub-county TB and Lab coordinators, Pharmacist, DOT Nurse, PHO, Physician, Counselor, Nutritionist and Social Worker.

4.3.2.2. Programm

atic Managem

ent of Drug Resistant TB

40

4.3.

2.2.

Pro

gram

mat

ic M

anag

emen

t of D

rug

Resi

stan

t TB

To ensure no delays in treatment initiation, county pharmacists should have buffer stock to start patients on treatment while awaiting the ordered supply of second line medications. In collaboration with the counties, we shall work to establish a structured way for ordering and delivery of both DR-TB as well as other first line anti-TB medicines from the procuring and distributing agent/authority direct to the counties.

Improve treatment outcomes for DR-TB patients, including:

• Strengthening active pharmacovigilance (monitoring, recording and reporting of ADR through TIBU and PPB platforms) and their management, including the availability of auxiliary drugs e.g. Thyroxin, antipsychotics, hearing aids and implants

• Lobbying for, procuring, distribution and use of pediatric friendly DR-TB combinations• Revision of the DR-TB clinical tools used for the day-to-day management of patients• Introduction of case management of DR-TB in the TIBU system, which includes robust pharmacovigilance and

checks and reminders for lab and clinical monitoring. Linkages to NTRL’s LIMS shall also be explored• Planning for, procuring, distribution and use of capreomycin as first choice injectable for new MDR TB patients

(and existing patients intolerant to the current injectables)• Advocating for acceleration and uptake of new molecules, such as bedaquiline and delaminid once available

in the market• Establishing 7 regionally distributed Centers of Excellence (CoEs) in the country to offer mentorship and

technical assistance, support supervision, referrals, investigations, admissions, and ADR managements • Provision of financial support to DR-TB patients and DOTS nurses in community-based models• In consultation with the central government, ensure health insurance coverage for all DR-TB patients - both

in-patient and ambulatory. This can be done by enrolling DR-TB patients onto NHIF scheme using part of their social support funds

• Finalizing, printing and dissemination of DR-TB workplace policy documents• Developing, printing and distributing guidelines on community-based DR-TB care• Availing 12 portable digital X-rays for hard-to-reach areas and MDR-TB contacts• Conducting DR-TB sensitization and CME meetings in the private sector in a bid to standardize DR-TB

surveillance and treatment across the country.

Contribution to NSP Impacts Outcomes (MDR-TB)

Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15%, by 2018 compared to 2014

• Increase case notification of MDR-TB to at least 75% of estimated prevalence (baseline TBD following DR survey)

• Ensure treatment success of at least 80% among all cases of DR-TB, by 2018

• Reduce by 50% severe adverse events caused by second-line drugs

Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, by 2018 (baseline TBD)

• Increase to 100% the proportion of MDR-TB patients who receive social protections, including food support and transportation subsidies

Table 6: Impact and Outcome Indicators for PMDT

41

PMD

T O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: S

tren

gthe

n sy

stem

s th

at s

uppo

rt P

MD

T

Num

ber

of

PMD

T fo

cal

pers

ons

at

NTL

D

Prog

ram

Rete

ntio

n of

PM

DT

foca

l pe

rson

at

N

TLD

Pr

ogra

mRe

tent

ion

of P

MD

T fo

cal

pers

on a

t N

TLD

Pro

gram

1Re

tent

ion

of

PMD

T fo

cal

pers

on a

t N

TLD

Pro

gram

1Re

tent

ion

of

PMD

T fo

cal

pers

on a

t N

TLD

Pro

gram

1

Rete

ntio

n of

PM

DT

foca

l per

son

at N

TLD

Pro

gram

1

Prop

orti

on o

f sc

hedu

led

quar

terl

y PM

DT

TWG

m

eeti

ngs

held

4 PM

DT

TWG

mee

ting

s he

ld y

earl

yH

old

quar

terl

y PM

DT

TWG

m

eeti

ngs

100%

Hol

d qu

arte

rly

PMD

T TW

G

mee

ting

s10

0%H

old

quar

terl

y PM

DT

TWG

m

eeti

ngs

100%

Hol

d qu

arte

rly

PMD

T TW

G

mee

ting

s10

0%

Prop

orti

on o

f co

unti

es w

ith

DR

pati

ents

wit

h fu

ncti

onal

PM

DT

team

s*F

unct

iona

l=do

cum

ente

d/m

inut

ed

mee

ting

s at

le

ast

once

qua

rter

ly

Esta

blis

h co

unty

-bas

ed

PMD

T te

ams*

to

ov

erse

e D

R-TB

pat

ient

man

agem

ent,

log

isti

cs

and

DR-

TB s

urve

illan

ce*C

ompo

sed

of

the

follo

win

g sp

ecia

litie

s at

a

min

imum

- T

B, H

IV,

Lab,

Pha

rmac

y, P

HO

, Ph

ysic

ian,

Cou

nsel

or, N

utri

tion

, soc

ial s

uppo

rt,

part

ners

and

cou

nty

adm

in/f

inan

ce/H

R

Esta

blis

h th

e co

mpo

siti

on,

crit

eria

an

d TO

R of

the

PMD

T co

unty

team

s10

%Th

e co

unty

PM

DT

team

s tr

ansa

ct

busi

ness

(a

t le

ast

quar

terl

y m

eeti

ngs)

. In

itia

l un

der

TA fr

om n

atio

nal o

ffic

e

60%

Qua

rter

ly r

evie

w m

eeti

ngs

100%

1. Q

uart

erly

rev

iew

mee

ting

s2.

Rev

iew

of t

he p

erfo

rman

ce o

f th

e PM

DT

team

s

100%

Prop

orti

on

of

sub-

coun

ties

w

ith

func

tion

al

PMD

T te

ams

Esta

blis

h su

bcou

nty

team

s in

200

sub

coun

ties

Esta

blis

h su

bcou

nty

team

s in

20

su

bcou

ntie

s5%

Esta

blis

h su

bcou

nty

team

s in

80

sub

coun

ties

25%

Esta

blis

h su

bcou

nty

team

s in

80

subc

ount

ies

60%

Esta

blis

h su

bcou

nty

team

s in

20

subc

ount

ies

75%

Prop

orti

on o

f co

unti

es w

ith

at l

east

2 b

eds

for

adm

issi

on

of

DR-

TB

pati

ents

in

cr

itic

al

cond

itio

n

Expa

nd a

dmis

sion

s fa

cilit

ies

equi

tabl

y ac

ross

th

e co

untr

y fo

r D

R-TB

pat

ient

s (a

t le

ast

2 be

ds

per

coun

ty f

or D

R-TB

)

Enga

ge t

he c

ount

y te

ams

and

carr

y ou

t fa

cilit

y as

sess

men

t/ m

appi

ng10

0%Es

tabl

ish

adm

issi

on f

acili

ties

in

20

coun

ties

40

%Es

tabl

ish

adm

issi

on f

acili

ties

in

fur

ther

17

coun

ties

75

%Es

tabl

ish

adm

issi

on f

acili

ties

in

furt

her

10 c

ount

ies

100%

Prop

orti

on

of

mal

nour

ishe

d D

R-TB

pa

tien

ts

acce

ssin

g nu

trit

iona

l sup

port

Dev

elop

men

t an

d di

ssem

inat

ion

of a

too

l fo

r so

cial

se

curi

ty

need

s (i.

e.

nutr

itio

n &

ot

her

soci

al

supp

ort)

; Pr

omot

e th

e av

aila

bilit

y of

nu

trit

iona

l an

d ot

her

soci

al s

uppo

rt f

or D

RTB

pati

ents

(S

tren

gthe

n nu

trit

ion

asse

ssm

ent,

co

unse

lling

and

soc

ial s

uppo

rt (N

AC

S))

a)

Dev

elop

a

tool

fo

r as

sess

ing

soci

al s

ecur

ity

need

s an

d b)

Pilo

t te

st it

c) C

onti

nue

prov

idin

g RU

TF/F

BF

20%

a)

Prov

isio

n of

nu

trit

iona

l su

ppor

t to

des

ervi

ng D

R TB

pa

tien

tsb)

Pr

int

and

diss

emin

ate

the

tool

fo

r so

cial

ne

eds

asse

ssm

ent

50%

Prov

isio

n of

com

preh

ensi

ve

soci

al

supp

ort

(incl

udin

g nu

trit

ion)

to

de

serv

ing

DR

TB p

atie

nts

60%

Prov

isio

n of

co

mpr

ehen

sive

so

cial

su

ppor

t (in

clud

ing

nutr

itio

n)

to

dese

rvin

g D

R TB

pa

tien

ts

70%

Polic

y do

cum

ent

on c

ross

-bor

der

DRT

BSe

t up

an

in

tera

genc

y/in

ter-

min

iste

rial

te

am

and

othe

r re

leva

nt b

odie

s to

add

ress

the

cro

ss

bord

er D

R-TB

pro

blem

Esta

blis

h th

e

inte

rage

ncy/

inte

r-m

inis

teri

al

team

on

cr

oss-

bord

er

DR-

TB

Fina

lize

polic

y do

cum

ent;

Bi

annu

al m

etin

gs1

Bian

nual

met

ings

Bian

nual

met

ings

Num

ber

of C

MEs

on

PMD

T ta

rget

ing

the

priv

ate

sect

or h

eld

Con

duct

DR-

TB s

ensi

tiza

tion

/CM

E m

eeti

ngs

in

the

priv

ate

sect

orQ

uart

erly

se

nsit

izat

ion

of

the

priv

ate

prac

titi

oner

s in

CM

Es a

nd

othe

r pr

ofes

sion

al o

rgan

izat

ions

in

mai

n to

wns

25Bi

-ann

ual

sens

itiz

atio

n of

th

e pr

ivat

e pr

acti

tion

ers

in

CM

Es a

nd o

ther

pro

fess

iona

l or

gani

zati

ons

in m

ain

tow

ns

20Bi

-ann

ual

sens

itiz

atio

n of

th

e pr

ivat

e pr

acti

tion

ers

in

CM

Es a

nd o

ther

pro

fess

iona

l or

gani

zati

ons

in m

ain

tow

ns

40Bi

-ann

ual

sens

itiz

atio

n of

th

e pr

ivat

e pr

acti

tion

ers

in

CM

Es

and

othe

r pr

ofes

sion

al

orga

niza

tion

s in

mai

n to

wns

60

4.3.2.2. Programm

atic Managem

ent of Drug Resistant TB

4.3.

2.2.

Pro

gram

mat

ic M

anag

emen

t of D

rug

Resi

stan

t TB

PMD

T O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

2: S

tren

gthe

n sy

stem

atic

sur

veill

ance

of

DR

-TB

Prop

orti

on

of

elig

ible

pa

tien

ts

acco

rdin

g to

al

gori

thm

tes

ted

usin

g G

eneX

pert

6,00

0 H

CW

s se

nsit

ized

and

tra

ined

on

DR-

TB*

(sur

veill

ance

and

man

agem

ent)

*Sho

uld

pref

erab

ly b

e in

tegr

ated

into

the

com

preh

ensi

ve

TB/H

IV c

urri

culu

m

Dev

elop

H

CW

s se

nsit

izat

ion

curr

icul

lum

40%

Sens

itiz

e 2,

000

HC

Ws

60%

Sens

itiz

e 2,

000

mor

e H

CW

s80

%Se

nsit

ize

2,00

0 m

ore

HC

Ws

100%

Dis

sem

inat

ion

and

use

of u

pdat

ed G

eneX

pert

di

agno

stic

alg

orit

hm a

cros

s al

l ser

vice

del

iver

y po

ints

Sens

itiz

e C

TLC

s an

d su

b-co

unty

co

ordi

nato

rs o

n re

vise

d ge

ne X

pert

al

gori

thm

du

ring

qu

arte

rly

data

re

view

mee

ting

s

Sens

itiz

e H

CW

s at

the

gen

e ex

pert

sit

es (1

20 f

acili

ties

)Se

nsit

ize

HC

Ws

at

the

addi

tion

al g

ene

expe

rt s

ites

(8

0 fa

cilit

ies)

Sens

itiz

e H

CW

s at

th

e ad

diti

onal

gen

e ex

pert

sit

es (

50

faci

litie

s)

Expa

nd

DR-

TB

surv

eilla

nce

to

cong

rega

te

sett

ings

(s

choo

ls,

pris

ons,

H

CW

s,

mig

rant

s po

pula

tion

s,

publ

ic

tran

spor

t -

mat

atus

th

roug

h as

soci

atio

ns).

Uti

lize

othe

r ex

isti

ng

and

inno

vati

ve s

trat

egie

s to

im

prov

e sa

mpl

e re

ferr

al e

.g.

use

of l

ocal

mea

ns t

o tr

ansp

ort

sam

ples

Map

out

the

tar

get

grou

ps a

nd l

ay

a ba

sic

plan

wit

h as

sist

ance

of

the

coun

ties

on

how

to

carr

y ou

t th

is

acti

vity

Enga

ge

the

targ

et

grou

ps

thro

ugh

se

nsit

izat

ion.

En

gage

a f

ew m

atat

u sa

ccos

in

the

iden

tifi

ed h

ard

to re

ach

area

s an

d es

tabl

ish

a w

orki

ng

rela

tion

ship

on

sa

mpl

e re

ferr

al s

yste

m

Con

tinu

e w

ith

sens

itiz

atio

n of

mor

e of

the

tar

get

grou

ps

and

mat

atu

sacc

os

a) C

onti

nue

wit

h se

nsit

izat

ion

of m

ore

of t

he t

arge

t gr

oups

an

d m

atat

u sa

ccos

b) R

evie

w t

he p

erfo

rman

ce o

f th

ese

appr

oach

es w

ith

the

aim

of

lear

ning

bes

t ap

proa

ches

”

Prop

orti

on

of

TB

retr

eatm

ent

pati

ents

w

ho

acce

ss G

ene

Xpe

rt t

est

at t

reat

men

t in

itia

tion

Stre

ngth

en r

outi

ne D

R-TB

sur

veila

nce

amon

g al

l TB

ret

reat

men

t ca

ses

by u

se o

f G

eneX

pert

te

st

TB

retr

eatm

ent

pati

ents

te

sted

us

ing

Gen

e X

pert

ann

ually

75%

TB

retr

eatm

ent

pati

ents

te

sted

us

ing

Gen

e X

pert

an

nual

ly

85%

TB

retr

eatm

ent

pati

ents

te

sted

us

ing

Gen

e X

pert

an

nual

ly

95%

TB r

etre

atm

ent

pati

ents

tes

ted

usin

g G

ene

Xpe

rt a

nnua

lly10

0%

Prop

orti

on

of

sym

ptom

atic

ho

useh

old*

co

ntac

ts o

f D

R TB

acc

ess

Gen

e X

pert

tes

t

*hou

seho

ld

incl

udes

sh

arin

g th

e sa

me

acco

mod

atio

n fa

cilit

ies

in d

orm

itori

es, p

riso

ns e

tc

Stre

ngth

en r

outi

ne D

R TB

sur

veill

ance

am

ong

all

sym

ptom

atic

hou

seho

ld c

onta

cts

of D

R-TB

ca

ses

a) S

ensi

tize

the

cou

nty

team

s on

th

e us

e of

GX

pert

for

sym

ptom

atic

co

ntac

ts

of

DR-

TB

at

quar

terl

y re

view

mee

ting

sb)

All

sym

ptom

atic

con

tact

s of

new

D

R-TB

pat

ient

s un

derg

o G

xper

t te

st

100%

a) A

ll sy

mpt

omat

ic c

onta

cts

of

new

D

R-TB

pa

tien

ts

unde

rgo

Gxp

ert

test

b)

Qua

rter

ly

revi

ew

of

all

non-

sym

ptom

atic

con

tact

s of

D

R TB

pat

ient

s

100%

a) A

ll sy

mpt

omat

ic c

onta

cts

of

new

D

R-TB

pa

tien

ts

unde

rgo

Gxp

ert

test

b)

Qua

rter

ly

revi

ew

of

all

non-

sym

ptom

atic

co

ntac

ts

of D

R-TB

pat

ient

s

100%

a) A

ll sy

mpt

omat

ic c

onta

cts

of

curr

ent

DR-

TB p

atie

nts

unde

rgo

Gxp

ert

test

b) Q

uart

erly

rev

iew

of

all

non-

sym

ptom

atic

con

tact

s of

DR-

TB

pati

ents

100%

Stra

tegi

c A

ppro

ach

3: E

nsur

e ti

mel

y in

itia

tion

of

DR

-TB

trea

tmen

t (w

ithi

n 1-

2 w

eeks

of

diag

nosi

s)

Prop

orti

on o

f ne

w D

R-TB

pat

ient

s en

rolle

d in

to

care

wit

hin

1-2

wee

ks o

f di

agno

sis

Pati

ent r

egis

trat

ion

imm

edia

tely

aft

er d

iagn

osis

Esta

blis

h an

d di

ssem

inat

e po

licy

and

mec

hani

sm t

o en

sure

pat

ient

re

gist

rati

on

imm

edia

tely

af

ter

diag

nosi

s

Mon

itor

ing

to

ensu

re

impl

emen

tati

on o

f th

is p

olic

y75

%Re

view

of

polic

y to

ens

ure

adap

tati

on10

0%M

onit

orin

g to

en

sure

im

plem

enta

tion

of

the

revi

sed

polic

y

100%

Prop

orti

on

of

new

D

R-TB

pa

tien

ts

wit

h st

anda

rdiz

ed

base

line

inve

stig

atio

ns

done

w

ithi

n 48

hou

rs o

f di

agno

sis

Stan

dard

ized

la

bora

tory

in

vest

igat

ions

fo

r al

l ne

w D

R TB

pat

ient

s do

ne w

ithi

n 1-

2 da

ys

of d

iagn

osis

(rec

eipt

of

resu

lts

at c

ount

y) a

nd

resu

lts

elec

tron

ical

ly d

ispa

tche

d w

ithi

n 24

-48

hour

s

Esta

blis

h an

d di

ssem

inat

e po

licy

50%

a) P

olic

y im

plem

enta

tion

b) M

onit

orin

g of

pol

icy

75%

a) P

olic

y im

plem

enta

tion

b) R

evie

w o

f po

licy

100%

a)

Revi

sed

polic

y im

plem

enta

tion

b) M

onit

orin

g of

pol

icy

100%

Ava

ilabi

lity

of

stan

dard

ized

an

d fr

ee

base

linea

nd

follo

w

up

inve

stig

atio

ns

(FBC

, U

ECs,

LFT

s, T

SH)

incl

udin

g ch

est

radi

ogra

ph

and

audi

omet

ry in

all

the

coun

ties

Esta

blis

h m

echa

nism

s to

su

ppor

t fr

ee

inve

stig

atio

ns

incl

udin

g au

diom

etry

and

CX

R. S

uppo

rt 2

00

new

pat

ient

s fo

r ba

selin

es a

nd 6

00

for

follo

w u

p in

vest

igat

ions

Esta

blis

h m

echa

nism

s to

su

ppor

t fr

ee

inve

stig

atio

ns

incl

udin

g au

diom

etry

an

d C

XR.

Su

ppor

t 40

0 ne

w

pati

ents

fo

r ba

selin

es

and

600

for

follo

w

up

inve

stig

atio

ns

Esta

blis

h m

echa

nism

s to

su

ppor

t fr

ee

inve

stig

atio

ns

incl

udin

g au

diom

etry

an

d C

XR.

Su

ppor

t 40

0 ne

w

pati

ents

fo

r ba

selin

es

and

600

for

follo

w

up

inve

stig

atio

ns

Esta

blis

h m

echa

nism

s to

su

ppor

t fr

ee

inve

stig

atio

ns

incl

udin

g au

diom

etry

and

CX

R.

Supp

ort

400

new

pat

ient

s fo

r ba

selin

es a

nd 6

00 f

or f

ollo

w u

p in

vest

igat

ions

Prop

orti

on o

f co

unti

es r

epor

ting

no

stoc

k-ou

t of

DR-

TB d

rugs

Ava

ilabi

lity

of

2nd

line

TB

med

icat

ions

at

th

e co

unty

lev

el t

o al

low

fas

ter

init

iati

on o

f tr

eatm

ent

Esta

blis

h m

echa

nism

s to

ava

il 2nd

lin

e TB

med

s at

the

cou

nty

60%

a) P

olic

y im

plem

enta

tion

b) M

onit

orin

g of

pol

icy

60%

a) P

olic

y im

plem

enta

tion

b) R

evie

w o

f po

licy

80%

a)

Revi

sed

polic

y im

plem

enta

tion

b) M

onit

orin

g of

pol

icy

100%

Prop

orti

on

of

sub-

coun

ties

w

ith

func

tion

al

MD

T te

ams

for

DR-

TB/H

IVC

onst

itut

e st

ruct

ured

mul

ti-d

isci

plin

ary

(DR-

TB/

HIV

mul

tidi

scip

linar

y te

ams)

clin

ical

tea

ms

at

the

low

est l

evel

pos

sibl

e (s

ub c

ount

y) to

init

iate

tr

eatm

ent

and

follo

w u

p ca

re (

com

pose

d of

su

bcou

nty

TB

coor

dina

tor,

sCM

LT,

sCA

SCO

, La

b, P

harm

acis

t, D

OT

Nur

se,

PHO

, Ph

ysic

ian,

C

ouns

elor

s, n

utri

tion

ist)

Supp

ort

esta

blis

hmen

t of

mon

thly

D

R-TB

cl

inic

al

mee

ting

s in

ea

ch

coun

ty (

10 p

ax t

o di

scus

s D

R-TB

pa

tien

ts m

anag

emen

t)

30%

Supp

ort

esta

blis

hmen

t of

m

onth

ly

DR-

TB

clin

ical

m

eeti

ngs

in e

ach

coun

ty (

10

pax

to d

iscu

ss D

R-TB

pat

ient

s m

anag

emen

t)

60%

Supp

ort

esta

blis

hmen

t of

m

onth

ly

DR-

TB

clin

ical

m

eeti

ngs

in

each

co

unty

(1

0 pa

x to

di

scus

s D

R-TB

pa

tien

ts m

anag

emen

t)

80%

Supp

ort

esta

blis

hmen

t of

m

onth

ly

DR-

TB

clin

ical

m

eeti

ngs

in

each

co

unty

(1

0 pa

x to

dis

cuss

DR-

TB p

atie

nts

man

agem

ent)

100%

PMD

T O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

4: Im

prov

e M

&E

and

trea

tmen

t ou

tcom

es f

or D

R T

B pa

tien

ts, i

nclu

ding

chi

ldre

n

Prop

orti

on o

f D

R-TB

pat

ient

s fo

r w

hom

AD

R re

port

s ar

e re

cord

ed,

and

refl

ect

adeq

uate

m

anag

emen

t, in

TIB

U

Stre

ngth

en

acti

ve

phar

mac

ovig

ilanc

e (m

onit

orin

g,

reco

rdin

g &

re

port

ing

of

AD

R th

roug

h TI

BU

and

PPB

plat

form

s)

and

thei

r m

anag

emen

t in

clud

ing

the

avai

labi

lity

of

auxi

liary

dr

ugs

e.g.

th

yrox

in,

anti

psyc

hoti

cs,

hear

ing

aids

and

impl

ants

a) I

nteg

rati

on o

f PV

int

o th

e TI

BU

syst

emb)

Pla

nnin

g fo

r th

e au

xilia

ry d

rugs

an

d ai

ds

a) I

nteg

rati

on o

f PV

int

o th

e TI

BU s

yste

m a

nd s

ensi

tiza

tion

of

th

e (s

ub)

coun

ty

coor

dina

tors

in Q

RMs

b) P

rocu

rem

ent,

dis

trib

utio

n an

d us

e of

the

aux

iliar

y dr

ugs

and

aids

”

50%

a)

Mon

itor

ing

the

use

of

TIBU

PV

pl

atfo

rms

and

stre

ngth

en e

xist

ing

gaps

b) P

rocu

rem

ent,

dis

trib

utio

n an

d us

e of

th

e au

xilia

ry

drug

s an

d ai

ds

60%

a)

Revi

ew

of

the

TIBU

PV

pl

atfo

rms

in l

ine

wit

h pr

evio

us

year

’s fi

ndin

gsb)

Pr

ocur

emen

t,

dist

ribu

tion

an

d us

e of

the

aux

iliar

y dr

ugs

and

aids

”

75%

Num

ber

of A

udio

met

er m

achi

nes

avai

labl

e in

th

e co

unti

esPr

ocur

e 47

aud

iom

eter

mac

hine

s on

e fo

r ea

ch

coun

tyPr

ocur

e 10

aud

iom

eter

mac

hine

s fo

r th

e H

igh

bude

rn c

ount

ies

10Pr

ocur

e 20

au

diom

eter

m

achi

nes

30Pr

ocur

e 17

au

diom

eter

m

achi

nes

47n/

an/

a

Prop

orti

on

of

TB

coor

dina

tors

us

ing

the

upda

ted

supe

rvis

ory

chec

klis

t co

veri

ng D

R-TB

Upd

ate

chec

k lis

t fo

r su

perv

isor

y/su

ppor

t vi

sits

to

ade

quat

ely

cove

r D

R-TB

or

desi

gn a

spe

cifi

c D

R-TB

too

l

Revi

se/d

esig

n ch

eckl

ist

for

supe

rvis

ory/

supp

ort

visi

t to

cov

er

DR-

TB

n/a

Repr

int

and

dist

ribu

te

the

supe

rvis

ory

chec

klis

30%

Mon

itor

th

e us

e of

th

e ch

eckl

ist

100%

Revi

se t

he c

heck

list

100%

Prop

orti

on o

f ch

ildre

n w

ith

DR-

TB a

cces

sing

th

e pe

diat

ric

form

ulat

ions

Proc

ure,

dis

trib

ute

and

use

pedi

atri

c fr

iend

ly

DR-

TB c

ombi

nati

ons

Plan

for

pro

cure

men

t of

ped

iatr

ic

frie

ndly

DR-

TB f

orm

ulat

ions

n/a

Proc

ure,

di

stri

bute

an

d us

e pe

diat

ric

frie

ndly

D

R-TB

fo

rmul

atio

ns

30%

Proc

ure,

dis

trib

ute

and

use

pedi

atri

c fr

iend

ly

DR-

TB

form

ulat

ions

60%

Proc

ure,

di

stri

bute

an

d us

e pe

diat

ric

frie

ndly

D

R-TB

fo

rmul

atio

ns

100%

Prop

orti

on

of

faci

litie

s pr

ovid

ing

TB

care

se

rvic

es s

uppl

ied

wit

h re

vise

d D

R-TB

too

lsRe

vise

the

DR-

TB c

linic

al t

ools

* us

ed f

or t

he

day

to d

ay m

anag

emen

t of

pat

ient

s

*pat

ient

too

ls, r

egis

ters

, IEC

mat

eria

ls e

tc”

Revi

se t

he c

linic

al t

ools

, pl

an f

or

proc

urem

ent

n/a

Proc

urem

ent,

di

stri

buti

on

and

use

of t

he t

ools

100%

Mon

itor

the

use

of

the

tool

s10

0%Re

vise

the

too

ls,

Proc

ure

and

dist

ribu

te t

he u

pdat

ed t

ools

100%

Upd

ated

TIB

U s

yste

m w

hich

inc

orpo

rate

s D

R-TB

cas

e m

anag

emen

tIn

trod

uce

case

man

agem

ent

of D

R-TB

in

the

TIBU

sys

tem

whi

ch in

clud

es r

obus

t ph

arm

aco-

vigi

lanc

e an

d ch

ecks

and

rem

inde

rs f

or la

b an

d cl

inic

al m

onit

orin

g. E

xplo

re l

inka

ges

to N

TRL’

s LI

MS

Des

ign

and

intr

oduc

e a

robu

st D

R-TB

ca

se

man

agem

ent

into

TI

BU

syst

em

1Pi

lot

test

th

e ne

w

desi

gn,

mak

e re

visi

ons

and

cond

uct

trai

ning

s of

th

e TB

of

fice

rs

coun

tryw

ide

Mon

itor

use

Revi

se t

he D

R-TB

int

erfa

ce a

nd

cont

ents

in

TIBU

in

line

wit

h ne

w p

roto

cols

. U

pdat

e of

fice

rs

in Q

RM

Prop

orti

on

of

elig

ible

ne

w

DR-

TB

pati

ents

ac

cess

ing

capr

eom

ycin

as

fi

rst

inje

ctab

le

of

choi

ce

Plan

fo

r, pr

ocur

e,

dist

ribu

te

and

use

capr

eom

ycin

as

firs

t ch

oice

inje

ctab

le f

or n

ew

MD

R-TB

pat

ient

s (&

exi

stin

g pa

tien

ts in

tole

rant

to

the

cur

rent

inje

ctab

les)

Plan

fo

r th

e pr

ocur

emen

t of

ad

equa

te s

tock

s of

cap

reom

ycin

25%

Proc

ure,

di

stri

bute

an

d us

e th

e ca

preo

myc

in50

%Pr

ocur

e, d

istr

ibut

e an

d us

e th

e ca

preo

myc

in75

%Pr

ocur

e, d

istr

ibut

e an

d us

e th

e ca

preo

myc

in10

0%

Prop

orti

on o

f new

DR-

TB p

atie

nts

acce

ssin

g th

e ne

w m

olec

ules

Adv

ocat

e fo

r ac

cele

rati

on a

nd u

ptak

e of

new

m

olec

ules

suc

h as

bed

aqui

line

and

dela

min

id

once

ava

ilabi

lity

in t

he m

arke

t

Adv

ocat

e fo

r th

e av

aila

bilit

y of

the

ne

w m

olec

ules

in t

he c

ount

ryn/

aPl

an

for,

proc

ure

and

dist

ribu

te t

he n

ew m

olec

ules

fo

r us

e

n/a

Plan

fo

r, pr

ocur

e an

d di

stri

bute

th

e ne

w

mol

ecul

es f

or u

se

10%

Plan

for

, pr

ocur

e an

d di

stri

bute

th

e ne

w m

olec

ules

for

use

25%

Num

ber

of

wor

kpla

ce

DR-

TB

polic

ies

dist

ribu

ted

Fina

lize,

pri

nt a

nd d

isse

min

ate

18,0

00 D

R-TB

w

orkp

lace

pol

icy

docu

men

tsW

orkp

lace

po

licy

copi

es

prin

ted

and

dist

ribu

ted

6,00

0W

orkp

lace

po

licy

copi

es

prin

ted

and

dist

ribu

ted

4,00

0W

orkp

lace

po

licy

copi

es

prin

ted

and

dist

ribu

ted

4,00

0W

orkp

lace

pol

icy

copi

es p

rint

ed

and

dist

ribu

ted

4,00

0

Num

ber o

f N95

mas

ks p

rocu

red

and

dist

ribu

ted

Proc

ure

and

dist

ribu

te 6

0,00

0 N

95 m

asks

Proc

ure

and

dist

ribu

te N

95 m

asks

10,0

00Pr

ocur

e an

d di

stri

bute

N

95

mas

ks20

,000

Proc

ure

and

dist

ribu

te N

95

mas

ks20

,000

Proc

ure

and

dist

ribu

te

N95

m

asks

10,0

00

Num

ber

of D

R-TB

CoE

s es

tabl

ishe

dEs

tabl

ish

7 re

gion

ally

di

stri

bute

d C

entr

es

of

Exce

llenc

e (C

oEs)

in

th

e co

untr

y to

of

fer

men

tors

hip/

TA,

supp

ort

supe

rvis

ion,

re

ferr

als,

inv

esti

gati

ons,

adm

issi

ons,

and

AD

R m

anag

emen

ts(T

he p

ropo

sed

site

s ar

e K

enya

tta

Nat

iona

l H

ospi

tal,

Daa

dab,

Moi

Tea

chin

g an

d Re

ffer

al, J

aram

ogi O

ging

a O

ding

a te

achi

ng a

nd

reff

eral

hos

pita

l, H

omab

ay, P

ortR

eitz

and

…..)

Dev

elop

the

bas

ic r

equi

rem

ents

for

a

mod

el D

R-TB

CoE

,and

a p

ackg

ae

carr

y ou

t m

appi

ng

n/a

Esta

blis

h 3

sele

cted

m

odel

D

R-TB

CoE

3Es

tabl

ish

4 m

ore

DR-

TB C

oEs

4M

ento

rshi

p7

Prop

orti

on o

f el

igib

le D

R-TB

pat

ient

s re

ceiv

ing

soci

al s

uppo

rt

Prov

isio

n of

fina

ncia

l sup

port

to D

R-TB

pat

ient

s an

d D

OTS

nur

ses

in c

omm

unit

y ba

sed

mod

els

Prov

ide

supp

ort

to 6

00 p

atie

nts

at

KSH

S 6,

000

each

and

200

HC

Ws

60%

Prov

ide

supp

ort

to

600

pati

ents

at

KSH

S 6,

000

each

an

d 20

0 H

CW

s

80%

Prov

ide

supp

ort

to

600

pati

ents

at

KSH

S 6,

000

each

an

d 20

0 H

CW

s

80%

Prov

ide

supp

ort

to 6

00 p

atie

nts

at K

SHS

6,00

0 ea

ch a

nd 2

00

HC

Ws

80%

Prop

orti

on

of

TB

pati

ents

en

rolle

d on

N

HIF

sc

hem

eYe

arly

pay

men

t to

NH

IF u

ntil

afte

r co

mpl

etio

n of

tre

atm

ent

NH

IF y

earl

y su

bscr

ipti

on f

or 6

00

pati

ents

NH

IF y

earl

y su

bscr

ipti

on f

or

600

pati

ents

20%

NH

IF y

earl

y su

bscr

ipti

on f

or

600

pati

ents

30%

NH

IF

year

ly

subs

crip

tion

fo

r 60

0 pa

tien

ts50

%

Prop

orti

on o

f co

unti

es u

tilit

izin

g co

mm

unit

y-ba

sed

DR-

TB g

uide

lines

Dev

elop

and

pri

nt g

uide

lines

on

com

mun

ity

base

d D

R-TB

car

eD

evel

op t

he c

omm

unit

y ba

sed

DR-

TB c

are

guid

elin

esPr

int,

di

ssem

inat

e an

d di

stri

bute

6,0

00 c

omm

unit

y D

R-TB

car

e gu

idel

ines

20%

Sens

itiz

atio

n of

2,

000

com

mun

ity

mem

bers

on

C

omm

unit

y D

R-TB

car

e

40%

Sens

itiz

atio

n of

2,

000

com

mun

ity

mem

bers

on

co

mm

unit

y D

R-TB

car

e

50%

4.3.2.2. Programm

atic Managem

ent of Drug Resistant TB

4.3.

2.3.

Ped

iatr

ic T

B4.

3.2.

2. P

rogr

amm

atic

Man

agem

ent o

f Dru

g Re

sist

ant T

B

PMD

T O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Num

ber

of d

igit

al x

-ray

fac

iliti

es in

the

cou

ntry

12

Dig

ital

X-r

ays

for

hard

to

reac

h ar

eas

and

MD

R-TB

con

tact

sM

apin

g of

the

har

d to

rea

ch a

reas

an

d pl

an

for

acqu

isit

ion

of

the

mob

ile X

-ray

equ

ipm

ent

Inst

all

and

oper

atio

naliz

e 4

xray

mac

hine

s4

Inst

all

and

oper

atio

naliz

e 4

xray

mac

hine

s4

Inst

all a

nd o

pera

tion

aliz

e 4

xray

m

achi

nes

4

4.3.2.3. Pediatric TB

1. Situational Analysis

The infant mortality rate in Kenya dropped from 68 per 1,000 live births in 2000 to 43.6 per 1,000 in 2012, indicating an improvement in the Kenyan health system. In 2012, 10,634 TB cases were reported among children under the age of 15, comprising 10.7% of all TB cases.

Almost 28% of all child TB cases were in children under the age of one. Of the reported TB cases, 93% were tested for HIV and 30% were found to be HIV positive. Of those found positive, 90% were initiated on cART and 99% on cotrimoxazole. In 2012, 10 children were diagnosed with MDR-TB and treatment started. Among the pediatric MDR-TB cases, 20% were HIV positive. In Kenya, it is estimated that 20% of the children under the age of 5 years suffer from moderate malnutrition, while 6% suffer from severe malnutrition. The pediatric case notification chart below highlights the disparities among counties in the percentage of notified paediatric cases.

There are counties that notified a very high number of children with Turkana and Samburu having >12% of their total cases being children while some have child TB cases being less than 5% of the total TB cases notified. It is also important to note that counties where there is food insecurity due to climatic characteristics had more children diagnosed with TB. Map 5 indicates the ratio of children <5 years to those 5-15 years diagnosed with TB.

According to WHO, it is expected this ratio is 1:1.5-3.0. However, over 70% of the counties have a ratio of less than 1.5. This is indicative of under-diagnosis of children below the age of 5 years. There is therefore a need to evaluate the actual diagnostic practices among health care workers in

8.3.

2.3.

Ped

iatr

ic T

B

4.3.2.3. Pediatric TB

Map 5: Ratio of <5 to 5-15 Year Olds, 2013 TB

Notifications

Map 4: % of Pediatric TB Cases among All

Notifications

Figure 15: Notified Pediatric TB Cases by County, 2013

46

4.3.

2.3.

Ped

iatr

ic T

B

these very high and very low case notification areas to ensure that we are not over or under-diagnosing the children.

Several strides have been made to support childhood TB as well as the case notification of TB among children under the age of 15. A pediatric TB focal person is currently based in the central program, and is supported by a Pediatric TB technical working group with expert representation from the NTLD Program, KEMRI, NASCOP, University of Nairobi, Moi Teaching and Referral Hospital, CDC Kenya, CHS and ICAP. National guidelines for management of childhood TB, job aids; including diagnostic and preventive algorithms, treatment charts, training curricula and tools have been developed with the working group’s consensus.

The treatment guidelines are in-line with current WHO recommendations, while health care worker trainings are in progress, based on the revised pediatric TB treatment algorithms. The GeneXpert algorithm supports the diagnosis of children under the age of 15 years using Xpert. Pediatric anti-TB formulations (dispersible fixed dose combinations, Isoniazid 100mg and Ethambutol 100mg) are available in Kenya through KEMSA. In addition, there exists a case based electronic recording system for monitoring TB program activities allowing evaluation of child TB data. However, this system does not capture nutrition assessment data for children with TB. There is need to improve the facility TB register to ensure it captures the nutrition indicators for children and the same should be incorporated into TIBU.

Currently, there is limited screening for TB among child TB contacts and children living with HIV, with a small proportion of those eligible receiving Isoniazid prophylaxis. Diagnosis of TB in children has been a major challenge in the scale up of child TB services. There is a low index of suspicion by HCWs for TB among children and most are ill equipped to make an accurate diagnosis of TB in children. Diagnosis is limited to the chest clinic with missed opportunities in maternal and child health (MCH) clinics, pediatric clinics, emergency rooms and in-patient wards. There remain financial and geographical barriers to quality diagnostic services for children due to limited access to affordable, high quality x-rays for TB diagnosis. GeneXpert machines, though currently available, are not strategically placed and networked to ensure equitable access to all children. In addition, TST is not readily available in most health facilities.

Children exposed to DR-TB have a high risk of acquiring the infection. Once a case of DR-TB has been diagnosed, it is important to screen all household contacts including the children for any signs and symptoms of disease. This is not routinely done, hence, some of these cases may be missed. Follow up should be done for all contacts for at least two years because the signs and symptoms may develop after some time. Diagnosis of DR-TB in children is a challenge as the index of suspicion is low among health care workers. Diagnosis may be delayed as attempts to obtain specimens for bacteriological confirmation may be challenging without adequate capacity building. Once DR-TB has been diagnosed, few health care workers are trained to adequately manage children. Adult formulations are used to treat DR-TB in children with dose challenges, which result in a higher risk of toxicity from the drugs.

For all children with TB, malnutrition is often comorbidity. There is need to train health care workers to effectively conduct a nutritional assessment for all children with TB and once diagnosed with malnutrition, these children need nutritional support and supplementation. This is not consistently available.

Figure 16: Child Versus Adult TB Cases

47

2. Strategic Direction(s) for 2015-2018

The focus for the next three (3) years is to ensure that there is more emphasis on distinct pediatric TB control activities. These will include: a) active pediatric TB case finding; b) management, prevention, advocacy and integration of child TB services in other departments; c) scale up and sustain gains made in child TB surveillance; d) strengthen TB/HIV care for children; and e) continue with capacity building activities for HCWs.

The adoption and rollout of new diagnostic technologies with improved diagnosis of TB in children using GeneXpert, chest x-rays and TST will be fast-tracked to ensure equitable access. The capacity of HCWs will be developed to enable them conduct nutritional assessments and manage malnutrition in children with TB. Capacity will also be developed for HCWs on child TB case detection, diagnosis and treatment. All child contacts of patients with TB will be actively traced, screened and offered Isoniazid Preventive Therapy if eligible. Community engagement in TB control will be enhanced, allowing for contact and defaulter tracing of children and for care of OVCs. There will be institutional based TB screening for children in schools and children homes.

Increased awareness and advocacy is required on childhood TB. There will be systematic involvement of private providers, pediatric providers’ associations and all other stakeholders in child TB control.

There is need to focus on scale up activities for child asthma and management of chronic lung conditions in children as well as better case detection and rehabilitation for children with leprosy. Counties will be encouraged to engage pediatric experts in management of children with TB, leprosy and lung disease and equip county hospitals with all relevant tools to support this.

3. Proposed Approaches

Interventions towards pediatric TB management have significantly improved over the last year with introduction of revised treatment schedules, pediatric friendly TB medicines and a simplified approach to diagnosis and availability of GeneXpert.

Currently, there are disparities in the rate of child TB notification across the country. Though it would be more strategic to use these disparities as a basis for targeting the interventions in this strategic plan, this will not be done because there is need to first establish the origin of these disparities. Therefore, in the first year of implementation, a retrospective evaluation of the patients and their characteristics may shed light as to why these disparities exist. In the meantime, the proposed approaches will be rolled out countrywide.

In the final phase of the implementation of this strategic plan, an evaluation to establish the impact and effectiveness of these approaches will be conducted.

Lessons learnt from this evaluation will form the basis for targeted interventions in subsequent strategic plans.

4.3.2.3. Pediatric TB

Lessons Learned

TB-REACH: Eldoret, Kenya

A pilot project supported by TB-REACH has nurtured collaboration with communities to screen symptomatic individuals and transport sputum samples to smear microscopy centers, while making linkages to care. AMPATH has introduced a cough monitoring system to monitor case detection activity. A child tracking component registers children living in smear positive households to establish a way to locate children at high risk of TB. Children benefit from a screening package through TB REACH, including transportation costs, registration fees, chest radiograph and physical exam. If a child tests positive, he/she begins treatment immediately, and if negative, begins Isoniazid preventative therapy. GeneXpert laboratories at district and sub-levels are facilitating timely diagnosis.

Geographical Focus

Centre(s) of Excellence

As the implementation of pediatric TB services is rolled out countrywide, some sites will be identified and strengthened as centers of excellence. These will be centers that will be able to offer comprehensive child TB, MDR TB and Lung health services from diagnosis, treatment and prevention. They will be model sites for mentorship of other service provision sites.

Intensified Technical Support

Training and technical assistance will be offered to all sites to build capacity to implement the revised treatment guidelines for child TB.

Box 2

Box 3

48

8.3.

2.3.

Ped

iatr

ic T

B

 

Strengthen coordination of child TB services

Coordination of pediatric TB services will be done by a focal person at the program. The pediatric TB TWG will continue to provide policy direction and oversight for the implementation of child TB services.

Build capacity of health care workers for pediatric TB control

Continuous training for health care workers on child TB diagnosis, management and prevention as part of routine TB trainings will build their capacity to better manage children with TB. We will ensure printing and dissemination of up-to-date guidelines and job aids to facilitate the HCWs in service provision. There is need to support mentorship programs and on job training.

Child TB should be included in pre-service training for all HCWs to build their capacity on the current pediatric curriculum, including the nutritional aspects. Additionally, registering the NTLD Program as a CPD provider may encourage senior doctors to attend trainings and CMEs on TB.

Integrate child TB with other specialties

There is need to develop linkages between MCH clinics, PMTCT sites, pediatric outpatient clinics, casualty, pediatric inpatient wards and the TB clinic. This will strengthen TB systems in these different areas to close any present gaps in the screening, diagnosis, treatment and prevention of child TB. Additionally, this will help monitor and facilitate patient and information flow between departments, while surveillance data needs to be improved, in order to capture nutritional aspects of TB in children.

To minimize TB transmission to children within the health care settings, efforts will be made to improve IPC activities in health facilities through triaging all adults with cough and separating them from children.

Child TB drug procurement and ordering should be in line with program needs to avoid over and under-stocking. All children should be actively monitored for adverse drug reactions. To facilitate this, ADR monitoring questions are to be incorporated in the current patient monitoring tools.

Ensure affordable, high quality TB diagnostics

All children need to access quality TB diagnostics at no cost. This requires setting aside funds at national and county government levels towards basic child TB diagnostics. CXR facilities will need to be availed, either through mobile digital CXR services or installation of quality CXR services that are accessible to lower level health facilities with improved capacity for reliable interpretation by linking these facilities with adequately trained radiologists. This can be done through web linkage.

Current child TB diagnostic algorithms and tools will have to be made available at all facilities dealing with children at all key areas of child-care. Xpert testing should be the first diagnostic test for children with expectorated/induced sputum samples or gastric aspirate samples. There will be skills development for HCWs through mentorship to develop their capacity to obtain sputum samples from children. In addition, there is need to link all TB diagnostic facilities to available Xpert sites to ensure access to diagnosis.

49

Prevention of TB through community engagement and IPT provision

Communities should be actively engaged in the management of TB through contact tracing, supervision of DOTS for TB patients and tracing patients who default from treatment. Child TB contacts can be actively traced through engagement of community health workers to ensure the children are screened and either put on TB treatment or preventive therapy. The Orphans and Vulnerable children are more likely to fall off their TB treatment due to a lack of social support. Community based programs can be developed for them to ensure completion of treatment and other social support they may need.

Awareness and TB screening campaigns shall be conducted in schools, colleges and orphanages to increase awareness about TB and intensify detection of new cases. Through the engagement of community health workers, there shall be active tracing for child contacts among various TB patients, including smear positive and MDR-TB patients. Reverse contact tracing has also been done among children with TB.

IPT has been shown to have a protective benefit for children exposed to TB and those living with HIV.

Contact tracing and intensified case finding should be done at the facility level to exclude active TB. Success in this will depend on collaboration between facilities and communities. Children diagnosed with TB should be started on effective treatment regimen, while those without TB should be initiated on Isoniazid therapy for a period of six months with periodic review to identify suggestive symptoms or to be reviewed as soon as suggestive symptoms of TB arise.

Scale up nutrition interventions among children with TB

All health facilities need to be adequately equipped with anthropometric equipment to ensure that HCWs can assess the nutrition status of children with TB. Children found to have moderate and severe malnutrition will then be given nutrition supplementation. The surveillance system needs to be improved to adequately capture nutrition indicators for children.

Strengthen TB/HIV management in children

All children with TB must be tested for HIV. There is need to strengthen early infant diagnosis for all children under 18 months of age with PCR. All children found with HIV should be offered cART and CPT at the earliest opportunity. Children under five years exposed to smear positive TB and those above one year of age living with HIV should all be initiated on IPT once active TB disease has been ruled out.

DR-TB among children

All child DR-TB contacts should be traced and screened for TB. Those who screen positive should be initiated on the appropriate DR-TB regimen and followed up appropriately. These children should be reviewed by specialists to ensure appropriate management. Social support will be necessary to enable the caregivers of these children bring them for daily DOTS and to enable them to access follow up investigations. Those who screen negative during DR-TB screening should be followed up regularly for at least two years. There is need for continuous lobbying for pediatric friendly DR-TB drug formulations.

Senior clinicians managing children with MDR-TB should receive further specialized training to enable them effectively offer the service and to train other clinicians.

Establish and equip chronic care clinics for asthma and other chronic childhood lung conditions

Children with chronic respiratory conditions need special care. Medications and equipment for managing chronic lung conditions in children are neither readily available nor affordable. These commodities and equipment need to be procured and distributed to peripheral health facilities at no cost to these children. There is need to establish specialized lung health clinics for children in at least all county referral health facilities. Capacity building for HCWs in the identification, management and follow-up of asthma and chronic childhood lung conditions. All children with chronic lung conditions should be screened for risk factors. There is also need to establish a surveillance system to capture data on child chronic lung conditions.

Operational research

There is need to strengthen operational research on child TB and chronic lung health. This can be achieved through a mentorship program steered by the NTLD Program to enable the CTLCs and sub-county TB coordinators to plan and implement operational research projects. Operational research should be conducted on:

1. Evaluation of pediatric TB over and under diagnosis in Kenya2. Diagnostic effectiveness of the screening algorithm and treatment of TB in children3. Outcome of MDR-TB in children and child MDR-TB contacts 4. Evaluate adverse drug effects with the new pediatric regimen5. MDR-TB prophylaxis for young children.

4.3.2.3. Pediatric TB

50

8.3.

2.3.

Ped

iatr

ic T

B

Contribution to NSP Impacts Outcomes (Pediatric)

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

Increase the proportion of children among all notified cases (TBD: prevalence survey)

Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014

Increase case notifications of MDR-TB in children by 10-15%

Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014

• Increase to 90% the proportion of children with TB and HIV who are initiated on cART within 2 months of TB treatment initiation

• Increase to 80% the proportion of child contacts, without TB, who receive IPT

Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014

Ensure treatment success of at least 90% among all DS forms of TB

Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy & other lung diseases, by 2018 (baseline TBD)

Increase to 95% the proportion of malnourished children with TB who access nutritional support

Impact 4: Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018

Increase by 10% the number of leprosy cases notified among children

Impact 5: Reduce morbidity due to chronic lung diseases (e.g. COPD, asthma)

Reduce the average number of acute episodes for children with asthma

Table 7: Impact and Outcome Indicators for Pediatric TB

51

Pedi

atri

c TB

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: S

tren

gthe

n co

ordi

nati

on o

f ch

ild T

B se

rvic

es

Num

ber

of p

edia

tric

ian

foca

l pe

rson

s at

NTL

D

Prog

ram

sup

port

edRe

tent

ion

of p

edia

tric

foc

al p

erso

n at

NTL

D P

rogr

amRe

tent

ion

of

pedi

atri

c fo

cal

pers

on a

t N

TLD

Pro

gram

1Re

tent

ion

of

pedi

atri

c fo

cal

pers

on

at

NTL

D

Prog

ram

1Re

tent

ion

of

pedi

atri

c fo

cal

pers

on a

t N

TLD

Pro

gram

1Re

tent

ion

of

pedi

atri

c fo

cal

pers

on a

t N

TLD

Pro

gram

1

Prop

orti

on o

f sc

hedu

led

quar

terl

y TW

G m

eeti

ngs

held

Hol

d qu

arte

rly

ped

TB

TWG

m

eeti

ngs

Hol

d qu

arte

rly

ped

TB

TWG

m

eeti

ngs

100%

Hol

d qu

arte

rly

paed

TB

TW

G m

eeti

ngs

100%

Hol

d qu

arte

rly

ped

TB

TWG

m

eeti

ngs

100%

Hol

d qu

arte

rly

ped

TB

TWG

m

eeti

ngs

100%

Stra

tegi

c A

ppro

ach

2: B

uild

cap

acit

y of

HC

Ws

for

pedi

atri

c TB

, lep

rosy

and

lung

hea

lth

Prop

orti

on o

f fa

cilit

ies

prov

ided

wit

h an

d us

ing

pedi

atri

c-re

late

d m

ater

ial b

y ty

pePr

inti

ng a

nd d

istr

ibut

ion

of 8

,000

co

pies

of

pe

diat

ric

TB

guid

elin

es

and

10,0

00

flip

char

ts

joba

ids,

m

anto

ux p

oste

rs 9

000,

dia

gnos

tic

algo

rith

m p

oste

rs 9

,000

Prin

ting

an

d di

stri

buti

on

of

4,00

0 co

pies

of

pedi

atri

c TB

gu

idel

ines

and

6,0

00 fl

ipch

arts

jo

baid

s,

man

toux

po

ster

s 6,

000,

di

agno

stic

al

gori

thm

po

ster

s 6,

000

50%

Prin

ting

an

d di

stri

buti

on

of

4,00

0 co

pies

of

pe

diat

ric

TB

guid

elin

es

and

4,00

0 fl

ipch

arts

jo

baid

s, m

anto

ux p

oste

rs

3,00

0,

diag

nost

ic

algo

rith

m p

oste

rs 3

,000

100%

n/a

100%

n/a

100%

Upd

ated

ped

iatr

ic T

B gu

idel

ines

Revi

ew o

f pe

diat

ric

TB g

uide

lines

Revi

ew

of

pedi

atri

c TB

gu

idel

ines

1Re

view

of

pe

diat

ric

TB

guid

elin

es1

Num

ber

of H

CW

tra

ined

on

pedi

atri

c TB

Trai

ning

of

8,

460

HC

Ws

on

pedi

atri

c TB

Trai

n 1,

410

HC

Ws(

1 t

rain

ing

per

coun

ty,

30pa

x ea

ch f

or 3

da

ys)

1,41

0Tr

ain

2,82

0 H

CW

s (2

tr

aini

ngs

per

coun

ty,

30pa

x ea

ch f

or 3

day

s)

2,82

0Tr

ain

2,82

0 H

CW

s (2

tra

inin

gs

per

coun

ty,

30pa

x ea

ch f

or 3

da

ys)

2,82

0Tr

ain

1,41

0 H

CW

s (1

tra

inin

g pe

r co

unty

, 30

pax

each

for

3

days

)

1,41

0

Num

ber

of H

CW

rea

ched

thr

ough

e-l

earn

ing

Dev

elop

e-

mod

ule

com

pone

nt

of

the

pedi

atri

c TB

gui

delin

ePe

d TB

tr

aini

ng

curr

icul

um

upda

ted

to in

clud

e e-

mod

ule

300

Trai

n 30

0 H

CW

s us

ing

the

E m

odul

e pe

diat

ric

TB t

rain

ing

Trai

n 30

0 H

CW

s us

ing

the

E m

odul

e pe

diat

ric

TB t

rain

ing

Num

ber

of

HC

Ws

and

pedi

atri

c pr

ofes

sion

als

reac

hed

thro

ugh

CM

Es a

nd a

ccre

dite

d75

2 Fa

cilit

y ba

sed

CM

Es c

ondu

cted

on

pe

diat

ric

TB(1

pe

r ye

ar

per

coun

ty)

Faci

lity

base

d C

MEs

con

duct

ed

on p

edia

tric

TB(

5 pe

r ye

ar p

er

coun

ty)

9023

5 Fa

cilit

y ba

sed

CM

Es

cond

ucte

d on

pe

diat

ric

TB (5

per

yea

r pe

r co

unty

)

241

235

Faci

lity

base

d C

MEs

co

nduc

ted

on p

eadi

atri

c TB

(5

per

year

per

cou

nty)

241

235

Faci

lity

base

d C

MEs

co

nduc

ted

on p

edia

tric

TB

(5

per

year

per

cou

nty)

180

278

pedi

atri

c TB

C

MEs

fo

r pr

ofes

sion

al

asso

ciat

ions

( 2

per

year

per

cou

nty)

45

pedi

atri

c TB

C

MEs

fo

r pr

ofes

sion

al

asso

ciat

ions

( 2

per

year

per

cou

nty)

4594

ped

iatr

ic T

B C

MEs

for

pr

ofes

sion

al

asso

ciat

ions

(2

per

yea

r pe

r co

unty

)

9494

pe

diat

ric

TB

CM

Es

for

prof

essi

onal

as

soci

atio

ns

(2

per

year

per

cou

nty)

9445

pe

diat

ric

TB

CM

Es

for

prof

essi

onal

ass

ocia

tion

s( 2

per

ye

ar p

er c

ount

y)

45

NTL

D P

rogr

am r

egis

tere

d as

a C

PD p

rovi

der

NTL

D P

rogr

am r

egis

tere

d as

a C

PD

prov

ider

Link

pe

d TB

tr

aini

ng

to

CPD

aw

ard

syst

ems

to

incr

ease

at

tend

ance

/dem

and

(Reg

istr

atio

n co

st

appr

ox

40,0

00)

1

Num

ber

of H

CW

s m

ento

red

on c

hild

hood

TB

and

HIV

Dev

elop

a m

ento

rshi

p ch

eckl

ist

for

pedi

atri

c TB

Dev

elop

a

men

tors

hip

chec

klis

t fo

r pe

diat

ric

TB20

in

10

co

unti

es20

in 1

0 co

unti

es20

in 1

4 co

unti

es20

in

13

co

unti

es

Prin

t an

d di

stri

bute

6,

000

men

tors

hip

chec

klis

ts

to

heal

th

faci

litie

s

Prin

t an

d di

stri

bute

3,0

00

men

tors

hip

chec

klis

ts t

o he

alth

fac

iliti

es (N

o. t

o be

de

term

ined

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3,00

0Pr

int

and

dist

ribu

te

3,00

0 m

ento

rshi

p ch

eckl

ists

to

he

alth

fa

cilit

ies

(No.

to

be

de

term

ined

)

3,00

0Pr

int

and

dist

ribu

te

3,00

0 m

ento

rshi

p ch

eckl

ists

to

heal

th

faci

litie

s (N

o. t

o be

det

erm

ined

)

TA o

f H

CW

s on

chi

ld T

B an

d H

IV

serv

ices

TA o

f H

CW

s on

chi

ld T

B an

d H

IV s

ervi

ces

in a

reas

w

ith

low

tes

ting

upt

ake

TA o

f H

CW

s on

chi

ld T

B an

d H

IV s

ervi

ces

in a

reas

wit

h lo

w

test

ing

upta

ke

TA o

f H

CW

s on

chi

ld T

B an

d H

IV s

ervi

ces

in a

reas

wit

h lo

w

test

ing

upta

ke

Stra

tegi

c A

ppro

ach

3: In

tegr

ate

child

TB

wit

h ot

her

spec

ialt

ies

Num

ber

of o

ther

chi

ld h

ealt

h gu

idel

ines

wit

h ch

ild T

B sc

reen

ing

and

diag

nost

ic a

lgor

ithm

sIn

corp

orat

e pe

ads

scre

enin

g an

d di

agno

stic

al

gori

thm

in

to

IMC

I, IM

AM

an

d ot

her

child

he

alth

gu

idel

ines

Inco

rpor

ate

pead

s sc

reen

ing

and

diag

nost

ic a

lgor

ithm

in

to

IMC

I, IM

AM

an

d ot

her

child

he

alth

gui

delin

es

10

4.3.2.3. Pediatric TB

4.3.

2.3.

Ped

iatr

ic T

B

Pedi

atri

c TB

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on o

f ch

ildre

n se

en i

n he

alth

fac

iliti

es

scre

ened

for

TB

and

docu

men

ted

Doc

umen

t al

l pr

esum

ptiv

e ch

ild T

B ca

ses

scre

ened

for

TB

Doc

umen

t al

l pr

esum

ptiv

e ch

ild

TB

case

s sc

reen

ed f

or T

B

60%

Doc

umen

t al

l pr

esum

ptiv

e ch

ild T

B ca

ses

scre

ened

for

TB

80%

Doc

umen

t al

l pre

sum

ptiv

e ch

ild

TB c

ases

scr

eene

d fo

r TB

95%

Stra

tegi

c A

ppro

ach

4: E

nsur

e ac

cess

to

high

-qua

lity

TB d

iagn

osti

cs f

or a

ll ch

ildre

n at

no

cost

; im

prov

e ac

cess

to

x-ra

y se

rvic

es f

or c

hild

ren

Prop

orti

on o

f in

tend

ed x

-ray

mac

ines

pro

cure

d48

dig

ital

xra

y m

achi

nes

proc

ured

( at

leas

t 1

per

coun

ty,

38 f

ixed

and

10

por

tabl

e)

n/a

n/a

Proc

ure

16 d

igit

al x

rays

100%

Proc

ure

16 d

igit

al x

rays

100%

Proc

ure

16 d

igit

al x

rays

100%

Num

ber

of r

adio

grap

hers

/HC

Ws

trai

ned

on x

-ray

ta

king

and

inte

rpre

tati

onTr

aini

ng

of

200

HC

Ws

on

xray

in

terp

reta

tion

n/a

n/a

Trai

ning

of

HC

Ws

on X

ray

taki

ng a

nd in

terp

reta

tion

100

Trai

ning

of

H

CW

s on

X

ray

taki

ng a

nd in

terp

reta

tion

50Tr

aini

ng

of

HC

Ws

on

Xra

y ta

king

and

inte

rpre

tati

on50

Prop

orti

on

of

pres

umpt

ive

child

TB

ca

ses

rece

ivin

g di

agno

stic

se

rvic

es

for

acti

ve

TB

thro

ugh

Xpe

rt,

wit

h ga

stri

c as

pira

tion

an

d m

anto

ux

Scal

e up

uti

lizat

ion

of g

eneX

pert

ut

ilisa

tion

for

chi

ld T

B di

agno

sis

by

stre

ngth

enin

g re

ferr

al n

etw

orks

for

sp

utum

Scal

e up

ut

iliza

tion

of

ge

neX

pert

uti

lizat

ion

for

child

TB

dia

gnos

is b

y st

reng

then

ing

refe

rral

net

wor

ks f

or s

putu

m

n/a

Scal

e up

ut

iliza

tion

of

ge

neX

pert

ut

iliza

tion

fo

r ch

ild T

B di

agno

sis

by

stre

ngth

enin

g re

ferr

al

netw

orks

for

spu

tum

60%

Scal

e up

ut

iliza

tion

of

ge

neX

pert

uti

lizat

ion

for

child

TB

dia

gnos

is b

y st

reng

then

ing

refe

rral

net

wor

ks f

or s

putu

m

80%

Scal

e up

ut

iliza

tion

of

ge

neX

pert

uti

lizat

ion

for

child

TB

dia

gnos

is b

y st

reng

then

ing

refe

rral

net

wor

ks f

or s

putu

m

95%

Men

tors

hip

of

HC

WS

on

Xpe

rt

: ga

stri

c as

pira

tion

and

man

toux

in

all c

ount

ies

Men

tors

hip

of

HC

WS

on

Xpe

rt

:gas

tric

as

pira

tion

an

d m

anto

ux t

o 18

0 H

CW

s (T

OTs

)

n/a

2 m

ento

rshi

p se

ssio

ns/

coun

ty/y

ear

each

20

pa

x fo

r H

CW

s on

Xpe

rt,

gast

ric

aspi

rati

on

and

man

toux

2 m

ento

rshi

p se

ssio

ns/c

ount

y/ye

ar e

ach

20 p

ax f

or H

CW

s on

X

pert

, ga

stri

c as

pira

tion

an

d m

anto

ux

2 m

ento

rshi

p se

ssio

ns/c

ount

y/ye

ar e

ach

20 p

ax f

or H

CW

s on

X

pert

, ga

stri

c as

pira

tion

an

d m

anto

ux

Stra

tegi

c A

ppro

ach

5: P

reve

ntio

n of

TB

thro

ugh

com

mun

ity

enga

gem

ent

and

IPT

prov

isio

n

Prop

orti

on o

f th

e co

ntac

ts o

f sm

ear-

posi

tive

TB,

M

DR-

TB a

nd c

hild

TB

case

s th

at a

re t

race

d an

d sc

reen

ed

Scal

e up

ch

ild

cont

act

scre

enin

g an

d re

ferr

al:

Trai

n 1,

200

CH

Ws

on

cont

act

scre

enin

g(at

leas

t 1

trai

ning

pe

r co

unty

)

20%

Trai

n 40

0 C

HW

s on

co

ntac

t sc

reen

ing

40%

Trai

n 40

0 C

HW

s on

co

ntac

t sc

reen

ing

60%

Trai

n 40

0 C

HW

s on

co

ntac

t sc

reen

ing

80%

Faci

litat

e C

HW

s to

con

duct

act

ive

cont

act

trac

ing

and

defa

ulte

r tr

acin

g fo

r 15

0,00

0 TB

pat

ient

s

Faci

litat

e C

HW

s to

co

nduc

t ac

tive

co

ntac

t tr

acin

g an

d de

faul

ter

trac

ing

for

50,0

00

TB

pati

ents

Faci

litat

e C

HW

s to

co

nduc

t ac

tive

co

ntac

t tr

acin

g an

d de

faul

ter

trac

ing

for

50,0

00

TB p

atie

nts

Faci

litat

e C

HW

s to

co

nduc

t ac

tive

co

ntac

t tr

acin

g fo

r 50

,000

TB

pati

ents

Esta

blis

h lin

kage

s fo

r O

VC

s w

ith

TB

to c

omm

unit

y su

ppor

tEs

tabl

ish

linka

ges

for

OV

Cs

wit

h TB

to

com

mun

ity

supp

ort

Esta

blis

h lin

kage

s fo

r O

VC

s w

ith

TB

to

com

mun

ity

supp

ort

Esta

blis

h lin

kage

s fo

r O

VC

s w

ith

TB t

o co

mm

unit

y su

ppor

tEs

tabl

ish

linka

ges

for O

VC

s w

ith

TB t

o co

mm

unit

y su

ppor

t

Num

ber

of s

choo

ls/c

olle

ges/

orph

anag

es in

whi

ch

all c

hild

ren

have

bee

n sc

reen

ed f

or T

BC

ondu

ct

targ

eted

cont

act/

mas

s sc

reen

ing

cam

paig

ns

to

108

sch

oo

ls/c

oll

eg

es/

orp

ha

na

ge

s (4

sc

hool

s pe

r co

unty

pe

r ye

ar

in

Kir

inya

ga,

Nai

robi

, Em

bu,

Mom

basa

, K

isum

u,

Mig

ori,

Hom

a Ba

y, T

hara

ka a

nd Is

iolo

)

n/a

n/a

Con

duct

tar

gete

d sc

hool

-ba

sed

cont

act/

mas

s sc

reen

ing

cam

paig

ns

to

36

scho

ols/

colle

ges

(4

scho

ols

per

coun

ty

per

year

in K

irin

yaga

, Nai

robi

, Em

bu, M

omba

sa, K

isum

u,

Mig

ori,

Hom

a Ba

y,

Thar

aka

and

Isio

lo )

36C

ondu

ct

targ

eted

sc

hool

-ba

sed

cont

act/

mas

s sc

reen

ing

cam

paig

ns

to

36

scho

ols/

colle

ges

(4 s

choo

ls p

er c

ount

y pe

r ye

ar i

n K

irin

yaga

, N

airo

bi,

Embu

, M

omba

sa,

Kis

umu,

M

igor

i, H

oma

Bay,

Th

arak

a an

d Is

iolo

)

36C

ondu

ct

targ

eted

sc

hool

-ba

sed

cont

act/

mas

s sc

reen

ing

cam

paig

ns

to

36

scho

ols/

colle

ges

36

Num

ber

of

scho

ols/

colle

ges

in

whi

ch

TB

awar

enes

s ca

mpa

igns

wer

e co

nduc

ted

Con

duct

sc

hool

-bas

ed

awar

enes

s ca

mpa

igns

to

228

scho

ols/

colle

ges

(at

leas

t 4

scho

ols

per

coun

ty p

er

year

)

n/a

n/a

Con

duct

ta

rget

ed

scho

ol-b

ased

aw

aren

ess

cam

paig

ns t

o 76

sch

ools

/co

llege

s (4

sc

hool

s pe

r co

unty

pe

r ye

ar

in

Kia

mbu

, M

uran

g'a,

M

eru,

Ker

ich,

Lam

u, T

aita

Ta

veta

, N

akur

u,

Wes

t Po

kot,

Si

aya,

K

ajia

do

Kir

inya

ga,

Nai

robi

, Em

bu,

Mom

basa

, K

isum

u,

Mig

ori,

Hom

a Ba

y,

Thar

aka

and

Isio

lo )

76C

ondu

ct

targ

eted

sc

hool

-ba

sed

aw

aren

ess

cam

paig

ns

to

76

scho

ols/

colle

ges

(4

scho

ols

per

coun

ty p

er y

ear

in

Kia

mbu

, M

uran

g'a,

M

eru,

K

eric

h,

Lam

u,

Tait

a Ta

veta

, N

akur

u,

Wes

t Po

kot,

Si

aya,

K

ajia

do

K

irin

yaga

, N

airo

bi,

Embu

, M

omba

sa,

Kis

umu,

M

igor

i, H

oma

Bay,

Th

arak

a an

d Is

iolo

)

76C

ondu

ct t

arge

ted

scho

ol-b

ased

aw

aren

ess

cam

paig

ns

to

76

scho

ols/

colle

ges

(4 s

choo

ls p

er

coun

ty

per

year

in

K

iam

bu,

Mur

ang'

a, M

eru,

Ker

ich,

Lam

u,

Tait

a Ta

veta

, N

akur

u,

Wes

t Po

kot,

Sia

ya, K

ajia

do K

irin

yaga

, N

airo

bi,

Embu

, M

omba

sa,

Kis

umu,

M

igor

i, H

oma

Bay,

Th

arak

a an

d Is

iolo

)

76

Prop

orti

on o

f ch

ild c

onta

cts,

wit

hout

TB,

who

re

ceiv

e IP

T In

itia

te

IPT

for

all

elig

ible

ch

ild

cont

acts

Init

iate

IP

T fo

r el

igib

le

child

co

ntac

ts20

%In

itia

te

IPT

for

elig

ible

ch

ild c

onta

cts

40%

Init

iate

IP

T fo

r el

igib

le

child

co

ntac

ts60

%In

itia

te

IPT

for

elig

ible

ch

ild

cont

acts

80%

Pedi

atri

c TB

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prin

ted

IPT

algo

rith

m p

oste

rsN

umbe

r of

IPT

alg

orit

hm p

oste

rs

prin

ted

and

dist

ribu

ted

Prin

t an

d di

stri

bute

IP

T al

gori

thm

pos

ters

8,00

0Pr

int

and

dist

ribu

te

IPT

algo

rith

m p

oste

rs4,

000

Prin

t an

d di

stri

bute

IP

T al

gori

thm

pos

ters

4,

000

n/a

n/a

Prop

orti

on o

f pr

egna

nt w

omen

scr

eene

d fo

r TB

at

AN

C s

ites

Dis

sem

inat

e sc

reen

ing

algo

rith

m

and

card

s to

AN

C s

ites

Dis

sem

inat

e sc

reen

ing

algo

rith

m a

nd c

ards

to

AN

C

site

s

10%

Dis

sem

inat

e sc

reen

ing

algo

rith

m

and

card

s to

A

NC

sit

es

40%

Dis

sem

inat

e sc

reen

ing

algo

rith

m a

nd c

ards

to

AN

C

site

s

60%

Dis

sem

inat

e sc

reen

ing

algo

rith

m

and

card

s to

A

NC

si

tes

80%

Sens

itiz

e al

l H

CW

s in

AN

C o

n TB

sc

reen

ing

in p

regn

ancy

Sens

itiz

e al

l H

CW

s in

AN

C o

n TB

scr

eeni

ng in

pre

gnan

cySe

nsit

ize

all

HC

Ws

in

AN

C o

n TB

scr

eeni

ng i

n pr

egna

ncy

Sens

itiz

e al

l H

CW

s in

AN

C o

n TB

scr

eeni

ng in

pre

gnan

cySe

nsit

ize

all

HC

Ws

in A

NC

on

TB s

cree

ning

in p

regn

ancy

Scre

en a

ll pr

egna

nt w

omen

for

TB

in p

regn

ancy

Scre

en a

ll pr

egna

nt w

omen

for

TB in

pre

gnan

cySc

reen

al

l pr

egna

nt

wom

en

for

TB

in

preg

nanc

y

Scre

en a

ll pr

egna

nt w

omen

for

TB in

pre

gnan

cySc

reen

all

preg

nant

wom

en f

or

TB in

pre

gnan

cy

Off

er I

PT t

o al

l el

igib

le p

regn

ant

mot

hers

w

ith

HIV

fo

und

not

to

have

act

ive

TB

Off

er

IPT

to

all

elig

ible

pr

egna

nt

mot

hers

w

ith

HIV

fo

und

not

to h

ave

acti

ve T

B

Off

er

IPT

to

all

elig

ible

pr

egna

nt

mot

hers

w

ith

HIV

fo

und

not

to

have

ac

tive

TB

Off

er

IPT

to

all

elig

ible

pr

egna

nt

mot

hers

w

ith

HIV

fo

und

not

to h

ave

acti

ve T

B

Off

er IP

T to

all

elig

ible

pre

gnan

t m

othe

rs w

ith

HIV

fou

nd n

ot t

o ha

ve a

ctiv

e TB

Stra

tegi

c A

ppro

ach

6: S

cale

up

nutr

itio

n in

terv

enti

ons

amon

g ch

ildre

n w

ith

TB

Prop

orti

on

of

child

ren

wit

h TB

as

sess

ed

for

nutr

itio

nal s

tatu

sBa

selin

e as

sess

men

t of

nu

trit

ion

equi

pmen

t di

stri

buti

on a

nd s

tatu

sBa

selin

e as

sess

men

t of

nu

trit

ion

equi

pmen

t di

stri

buti

on a

nd s

tatu

s

n/a

100%

100%

100%

Proc

ure

and

dist

ribu

te 1

,500

adu

lt

wei

ghin

g sc

ales

wit

h st

adio

met

ers,

4,

000

pedi

atri

c be

am

bala

nce

scal

es

n/a

Proc

ure

500

adul

t w

eigh

ing

scal

es

wit

h st

adio

met

ers,

2,

000

pedi

atri

c be

am

bala

nce

scal

es

Proc

ure

500

adul

t w

eigh

ing

scal

es w

ith

stad

iom

eter

s,1,

000

pedi

atri

c be

am b

alan

ce s

cale

s

Proc

ure

500

adul

t w

eigh

ing

scal

es w

ith

stad

iom

eter

s, 1

,000

pe

diat

ric

beam

bal

ance

sca

les

Dis

trib

ute

500

adul

t w

eigh

ing

scal

es

wit

h st

adio

met

ers,

2,

000

pedi

atri

c be

am

bala

nce

scal

es

Dis

trib

ute

500

adul

t w

eigh

ing

scal

es

wit

h st

adio

met

ers,

1,

000

pedi

atri

c be

am b

alan

ce

scal

es

Dis

trib

ute

500

adul

t w

eigh

ing

scal

es w

ith

stad

iom

eter

s, 1

,000

pe

diat

ric

beam

bal

ance

sca

les

Serv

ice

cont

ract

s fo

r 1,

500

adul

t w

eigh

ing

scal

es w

ith

stad

iom

eter

s an

d 4,

000

pedi

atri

c be

am b

alan

ce

scal

es

n/a

Serv

ice

cont

ract

s fo

r 50

0 ad

ult

wei

ghin

g sc

ales

w

ith

stad

iom

eter

s an

d 2,

000

pedi

atri

c be

am

bala

nce

scal

es

Serv

ice

cont

ract

s fo

r 1,

000

adul

t w

eigh

ing

scal

es

wit

h st

adio

met

ers

and

3,00

0 pe

diat

ric

beam

bal

ance

sca

les

Serv

ice

cont

ract

s fo

r 1,

500

adul

t w

eigh

ing

scal

es

wit

h st

adio

met

ers

and

4,00

0 pe

diat

ric

beam

bal

ance

sca

les

Impr

ove

TB s

urve

illan

ce d

ata

tool

s to

capt

ure

child

TB

nu

trit

ion

asse

ssm

ent

data

Impr

ove

TB s

urve

illan

ce d

ata

tool

s to

capt

ure

child

TB

nu

trit

ion

asse

ssm

ent

data

n/a

n/a

n/a

Prop

orti

on

of

child

ren

wit

h m

oder

ate/

seve

re

mal

nutr

itio

n an

d TB

w

ho

rece

ive

nutr

itio

nal

supp

ort

Prov

ide

nutr

itio

n su

ppor

t to

80%

of

ch

ildre

n w

ith

mod

erat

e/se

vere

m

alnu

trit

ion

and

TB

Ass

ess

all

child

ren

wit

h TB

for

nu

trit

ion

stat

us40

%A

sses

s al

l ch

ildre

n w

ith

TB f

or n

utri

tion

sta

tus

60%

Ass

ess

all

child

ren

wit

h TB

for

nu

trit

ion

stat

us80

%A

sses

s al

l ch

ildre

n w

ith

TB f

or

nutr

itio

n st

atus

95%

40%

of

ch

ildre

n w

ith

mod

erat

e/se

vere

m

alnu

trit

ion

and

TB

rece

ive

nutr

itio

n su

ppor

t

60%

of

ch

ildre

n w

ith

mo

de

ra

te

/se

ve

re

mal

nutr

itio

n an

d TB

re

ceiv

e nu

trit

ion

supp

ort

80%

of

ch

ildre

n w

ith

mod

erat

e/se

vere

m

alnu

trit

ion

and

TB

rece

ive

nutr

itio

n su

ppor

t

95%

of

ch

ildre

n w

ith

mod

erat

e/se

vere

m

alnu

trit

ion

and

TB re

ceiv

e nu

trit

ion

supp

ort

Proc

ure

and

dist

ribu

te

nutr

itio

nal

supp

lem

enta

tion

(rea

dy

to

use

ther

apeu

tic

food

s RU

TF,

fort

ifie

d bl

ende

d fo

ods

FBFs

, M

ulti

ple

mic

ronu

trie

nts)

fo

r ch

ildre

n w

ith

mod

erat

e/

seve

re m

alnu

trit

ion

and

TB

Proc

ure

and

dist

ribu

te

nutr

itio

nal

sup

ple

men

tati

on

(rea

dy

to u

se t

hera

peut

ic f

oods

RU

TF,

fort

ifie

d bl

ende

d fo

ods

FBFs

, M

ulti

ple

mic

ronu

trie

nts)

fo

r ch

ildre

n w

ith

mod

erat

e /

seve

re

mal

nutr

itio

n an

d TB

Proc

ure

and

dist

ribu

te

nutr

itio

nal

supp

lem

enta

tion

(rea

dy

to

use

ther

apeu

tic

food

s RU

TF,

fort

ifie

d bl

ende

d fo

ods

FBFs

, M

ulti

ple

mic

ronu

trie

nts)

fo

r ch

ildre

n w

ith

mod

erat

e /

seve

re m

alnu

trit

ion

and

TB

Proc

ure

and

dist

ribu

te

nutr

itio

nal

supp

lem

enta

tion

(rea

dy

to

use

ther

apeu

tic

food

s RU

TF,

fort

ifie

d bl

ende

d fo

ods

FBFs

, M

ulti

ple

mic

ronu

trie

nts)

fo

r ch

ildre

n w

ith

mod

erat

e / s

ever

e m

alnu

trit

ion

and

TB

4.3.2.3. Pediatric TB

Pedi

atri

c TB

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

7: S

tren

gthe

n TB

/HIV

man

agem

ent

in c

hild

ren

Prop

orti

on o

f ch

ildre

n w

ith

TB w

ho a

re t

este

d fo

r H

IVTe

st 9

5% o

f ch

ildre

n w

ith

TB f

or

HIV

Test

chi

ldre

n w

ith

TB f

or H

IV93

%Te

st c

hild

ren

wit

h TB

for

H

IV94

%Te

st c

hild

ren

wit

h TB

for

HIV

95%

Test

chi

ldre

n w

ith

TB f

or H

IV95

%

Perc

enta

ge o

f H

IV e

xpos

ed c

hild

ren

< 1

8mon

ths

wit

h TB

wit

h co

nfir

mat

ory

HIV

PC

R te

stin

gTe

st

95%

H

IV

expo

sed

child

ren

<

18m

onth

s w

ith

TB

wit

h co

nfir

mat

ory

HIV

PC

R te

stin

g

Test

H

IV

expo

sed

child

ren

<

18m

onth

s w

ith

TB

wit

h co

nfir

mat

ory

HIV

PC

R te

stin

g

75%

Test

HIV

exp

osed

chi

ldre

n <

18m

onth

s w

ith

TB w

ith

conf

irm

ator

y H

IV

PCR

test

ing

80%

Test

H

IV

expo

sed

child

ren

<

18m

onth

s w

ith

TB

wit

h co

nfir

mat

ory

HIV

PC

R te

stin

g

90%

Test

H

IV

expo

sed

child

ren

<

18m

onth

s w

ith

TB

wit

h co

nfir

mat

ory

HIV

PC

R te

stin

g

95%

Perc

enta

ge o

f ch

ildre

n w

ith

TB a

nd H

IV in

itia

ted

on A

RT w

ithi

n 2

mon

ths

of T

B tr

eatm

ent i

niti

atio

nIn

itia

te 9

0% o

f ch

ildre

n w

ith

TB

and

HIV

on

ART

wit

hin

2 m

onth

s of

TB

tre

atm

ent

init

iati

on

Init

iate

chi

ldre

n w

ith

TB a

nd

HIV

on

ART

wit

hin

2 m

onth

s of

TB

tre

atm

ent

init

iati

on

84%

Init

iate

chi

ldre

n w

ith

TB

and

HIV

on

ART

wit

hin

2 m

onth

s of

TB

trea

tmen

t in

itia

tion

87%

Init

iate

chi

ldre

n w

ith

TB a

nd

HIV

on

ART

wit

hin

2 m

onth

s of

TB

tre

atm

ent

init

iati

on

90%

Init

iate

ch

ildre

n w

ith

TB

and

HIV

on

ART

wit

hin

2 m

onth

s of

TB

tre

atm

ent

init

iati

on

90%

Prop

orti

on o

f ch

ildre

n w

ith

TB a

nd H

IV w

ho a

re

init

iate

d on

CPT

Init

iate

100

% o

f ch

ildre

n w

ith

TB

and

HIV

on

CPT

Init

iate

chi

ldre

n w

ith

TB a

nd

HIV

on

CPT

99%

Init

iate

chi

ldre

n w

ith

TB

and

HIV

on

CPT

100%

Init

iate

chi

ldre

n w

ith

TB a

nd

HIV

on

CPT

100%

Init

iate

ch

ildre

n w

ith

TB

and

HIV

on

CPT

100%

Stra

tegi

c A

ppro

ach

8: S

tren

gthe

n PM

DT

and

cont

act

trac

ing

amon

g ch

ildre

n

Prop

orti

on o

f ch

ild c

onta

cts

acti

vely

tra

ced

and

scre

ened

C

ondu

ct

acti

ve

cont

act

trac

ing

and

scre

enin

g of

chi

ld c

onta

cts

for

100%

of

pati

ents

wit

h D

RTB-

Con

duct

act

ive

cont

act

trac

ing

and

scre

enin

g of

chi

ld c

onta

cts

for

pati

ents

wit

h D

R-TB

50%

Con

duct

ac

tive

co

ntac

t tr

acin

g an

d sc

reen

ing

of

child

con

tact

s fo

r pat

ient

s w

ith

DR-

TB

100%

Con

duct

act

ive

cont

act

trac

ing

and

scre

enin

g of

chi

ld c

onta

cts

for

pati

ents

wit

h D

R-TB

100%

Con

duct

act

ive

cont

act

trac

ing

and

scre

enin

g of

chi

ld c

onta

cts

for

pati

ents

wit

h D

R-TB

100%

Num

ber

of

seni

or

clin

icia

ns

trai

ned

on

man

agem

ent

of D

R-TB

Trai

n 6

seni

or

clin

icia

ns

on

man

agem

ent

of D

R-TB

(The

UN

ION

tr

aini

ng)

n/a

n/a

Trai

n se

nior

clin

icia

ns o

n m

anag

emen

t of

DR-

TB

(The

UN

ION

tra

inin

g)

2Tr

ain

seni

or

clin

icia

ns

on

man

agem

ent

of

DR-

TB (

The

UN

ION

tra

inin

g)

2Tr

ain

seni

or

clin

icia

ns

on

man

agem

ent

of

D

R-TB

(T

he

UN

ION

tra

inin

g)

2

Num

ber

of p

aed

DR-

TB f

orm

ulat

ions

ava

ilabl

e fo

r ch

ildre

nEn

sure

un

inte

rrup

ted

supp

ly

of

paed

fr

iend

ly

paed

D

R-TB

fo

rmul

atio

ns f

or 1

10 c

hild

ren-

Ensu

re

unin

terr

upte

d su

pply

of

pae

d fr

iend

ly p

aed

DR-

TB

form

ulat

ions

for

chi

ldre

n

20En

sure

un

inte

rrup

ted

supp

ly

of

paed

fr

iend

ly

paed

DR-

TB f

orm

ulat

ions

fo

r ch

ildre

n

25En

sure

un

inte

rrup

ted

supp

ly

of

paed

fr

iend

ly

paed

D

RTB

form

ulat

ions

for

chi

ldre

n

30En

sure

un

inte

rrup

ted

supp

ly

of

ped

frie

ndly

pe

d D

R-TB

fo

rmul

atio

ns f

or c

hild

ren

35

Num

ber

of

child

ren

wit

h D

R-TB

at

tend

ing

trea

tmen

t an

d D

OTS

Prov

ide

supp

ort

for

110

child

ren

wit

h D

R-TB

to

at

tend

tr

eatm

ent

and

DO

TS

Prov

ide

supp

ort

for

child

ren

wit

h D

R-TB

to

at

tend

tr

eatm

ent

and

DO

TS

20Pr

ovid

e su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB

to

atte

nd

trea

tmen

t an

d D

OTS

25Pr

ovid

e su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB

to

atte

nd

trea

tmen

t an

d D

OTS

30Pr

ovid

e su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB t

o at

tend

tre

atm

ent

and

DO

TS

35

Num

ber

of

child

ren

wit

h D

R-TB

re

ceiv

ing

nutr

itio

nal s

uppo

rtPr

ovid

e nu

trit

ion

supp

ort

for

110

child

ren

wit

h D

R-TB

Prov

ide

nutr

itio

n su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB20

Prov

ide

nutr

itio

n su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB25

Prov

ide

nutr

itio

n su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB30

Prov

ide

nutr

itio

n su

ppor

t fo

r ch

ildre

n w

ith

DR-

TB35

Num

ber

of f

ollo

w-u

p in

vest

igat

ions

con

duct

ed

for

child

ren

wit

h D

R-TB

Pr

ovid

e su

ppor

t fo

r fo

llow

-up

inve

stig

atio

ns f

or 1

10 c

hild

ren

wit

h D

R-TB

Prov

ide

supp

ort

for

follo

w-

up i

nves

tiga

tion

s fo

r ch

ildre

n w

ith

DR-

TB

20Pr

ovid

e su

ppor

t fo

r fo

llow

-up

inve

stig

atio

ns

for

child

ren

wit

h D

R-TB

25Pr

ovid

e su

ppor

t fo

r fo

llow

-up

inv

esti

gati

ons

for

child

ren

wit

h D

R-TB

30Pr

ovid

e su

ppor

t fo

r fo

llow

-up

inve

stig

atio

ns f

or c

hild

ren

wit

h D

R-TB

35

Prop

orti

on o

f D

R-TB

chi

ld c

onta

cts

follo

wed

up

for

at le

ast

2 ye

ars

Follo

w

up

90%

D

R-TB

ch

ild

cont

acts

for

at

leas

t 2

year

sFo

llow

up

DR-

TB c

hild

con

tact

s fo

r at

leas

t 2

year

s50

%Fo

llow

up

D

R-TB

ch

ild

cont

acts

fo

r at

le

ast

2 ye

ars

70%

Follo

w u

p D

R-TB

chi

ld c

onta

cts

for

at le

ast

2 ye

ars

80%

Follo

w u

p D

R-TB

chi

ld c

onta

cts

for

at le

ast

2 ye

ars

90%

Stra

tegi

c A

ppro

ach

8: C

omm

odit

y M

anag

emen

t an

d Ph

arm

acov

igila

nce

Num

ber

of

st

ock

outs

of

pa

edia

tric

TB

fo

rmul

atio

nsEn

sure

ste

ady

supp

ly o

f pa

ed T

B fo

rmul

atio

nsEn

sure

ste

ady

supp

ly o

f pa

ed

TB f

orm

ulat

ions

Ensu

re

stea

dy

supp

ly

of

paed

TB

form

ulat

ions

Ensu

re s

tead

y su

pply

of

paed

TB

for

mul

atio

nsEn

sure

ste

ady

supp

ly o

f pae

d TB

fo

rmul

atio

ns

Prop

orti

on o

f ch

ildre

n on

TB

trea

tmen

t re

view

ed

for

AD

RsRe

vise

th

e pa

tien

t re

cord

ca

rd

to

capt

ure

phar

mac

ovig

ilanc

e in

form

atio

n.

AD

R m

onit

orin

g fo

r 10

0% c

hild

ren

on T

B tr

eatm

ent

Revi

se t

he p

atie

nt r

ecor

d ca

rd

to c

aptu

re p

harm

acov

igila

nce

info

rmat

ion.

A

DR

mon

itor

ing

for

100%

ch

ildre

n on

TB

tr

eatm

ent

100%

AD

R m

onit

orin

g fo

r 10

0%

child

ren

on

TB

trea

tmen

t

100%

AD

R m

onit

orin

g fo

r 10

0%

child

ren

on T

B tr

eatm

ent

100%

AD

R m

onit

orin

g fo

r 10

0%

child

ren

on T

B tr

eatm

ent

100%

4.3.

2.3.

Ped

iatr

ic T

B

4.3.2.4. Leprosy

1. Situational Analysis

Kenya is considered to be in the post-elimination phase of leprosy, having achieved the WHO elimination target of less than 1 case per 10,000 people in 1989. The number of new leprosy cases in the country has continued to steadily decline over the past three decades from more than 600 to 139 in 1986 and 2013 respectively. Despite the low number of reported cases, leprosy continues to cause high morbidity among those infected, with 48% of new cases notified in 2013 having advanced disease with disability grade 1 and 2.

Active transmission is ongoing in communities in both endemic and non-endemic areas. Childhood cases (the marker of active transmission) account for 1 in 5 (21%) of all new cases1. There are still pockets of leprosy in a number of counties. Kwale and Kilifi reported the most new cases in 2012, followed closely by Kisumu, as shown in Map 6.

Recent active leprosy case-finding exercises conducted in Kwale and Kisumu counties yielded remarkable numbers of new cases. Most cases were infectious Multi-Bacillary (MB) leprosy, including those affecting children. A large proportion of disability grade 2 among patients reported in 2013 implied late diagnosis of leprosy in Kenya.

The country continues to build the capacity of county and sub-county TB/Leprosy coordinators to diagnose and manage uncomplicated cases, and has recently developed a training curriculum for health care providers. Guidelines for leprosy management have been integrated within the National TB treatment guidelines, and are available country-wide. Similarly, recording and reporting structures have been integrated within the national web-based surveillance system (TIBU), making leprosy case-based data available at the national level.

Leprosy is a debilitating disease common among the poor. Thus, there is need for a multi-sectorial approach to ensure successful integration of those affected, into the community. Other than physical presence of disease, there are social, economic and legal issues that work against the patient. They must be addressed (Public Health Act, Cap 242). Deliberate efforts need to be made to ensure that leprosy patients with disabilities benefit from the disability management program as provided for in the constitution.

Despite the gains made in leprosy control, the recently concluded mid-term review highlighted a number of gaps and challenges that impact on leprosy control. They include:

• Low index of suspicion for leprosy among general health care workers in geographically endemic areas, suggesting that not all leprosy cases are being detected and late diagnosis remains a challenge as reflected by the high rates of disability

• Low level of awareness in the community/general population on leprosy, delaying health seeking behavior as underscored by high disability rates

• Inadequate attention paid to rehabilitative services, including those for special patient needs, such as prevention of disabilities, physical and social rehabilitation

• Lack of educational materials on leprosy in the entire country.

2. Strategic Direction(s) for 2015-2018

During the four-year period, a two-tiered strategy will differentially address: a) endemic areas; and b) non-endemic areas. Specifically, the strategy will aim to: a) appropriately increase the index of suspicion among health workers, especially in the 5 endemic counties; b) raise public awareness; and c) improve the quality of surveillance, clinical care and rehabilitation, and monitoring and evaluation.

_______________________________________________________________________________________________________________________________1 Endemic areas include: Kilifi, Kwale, Malindi, Kisumu, Siaya, Busia; and non-endemic areas include Mbeere, Nyatike, Isiolo, Igembe, Kisumu east, Kericho/Buret, Nakuru, Mumias, Nandi, Bugoma South, Busia, Kakamega Central, Bunyala, Butere, Teso, Dagoretti , Kirinyaga, Nyeri North, GanjoniMombasa), Taita , Taveta, Tharaka, Kitui , Kyuso, Mwingi, Kibwezi, Maara.

4.3.2.4. Leprosy

56

Map 6: Leprosy Case Notification

4.3.

2.4.

Lep

rosy

3. Proposed Approaches

Improving public awareness and political commitment

A communication strategy will be developed. It will consider the different needs for endemic and non-endemic areas, and will include activities such as the relevant use of IEC materials, circulated and displayed in appropriate public areas. The communication strategy will also include commemoration of World Leprosy Day. In endemic areas, there should be radio and television messages as well as public campaign activities to raise awareness about leprosy, encouraging early care seeking and discouraging stigma. School health talks on leprosy will be initiated in endemic areas.

Capacity building of general care providers

a) Human resource capacity building will be done by the county, with technical assistance from the NTLD Program, in both endemic and non-endemic areas through:

i. Inclusion of a leprosy training module in the ongoing TB/HIV, DR-TB and CTBC trainings.

ii. Training of general health care workers on the use of the revised recording and reporting tools. Training of new county and sub coordinators in leprosy clinical and programmatic management. Capacity building of leprosy managers on advanced leprosy control management will also be rolled out in the five endemic areas.

b) In endemic areas: i. Develop a robust plan for building and sustaining capacity for leprosy identification and management by all health care workers. Train and retrain general health care workers on diagnosis, management, and recording and reporting of leprosy cases at all levels. Develop on-the-job training tools and disseminate for use by general health care workers. These concern the use of the revised recording and reporting tools. Hold refresher courses for lab staff of AFB–leprosy (Microscopy) and histo-pathologists. Engage skin specialists in training of health care workers on leprosy. Intensify training of new county and sub-county coordinators in leprosy clinical and programmatic management.

ii. Continuously sensitize/orientate health care providers to improve the index of suspicion for early leprosy diagnosis and management.

Leprosy surveillance and active case finding

Several approaches will be used for surveillance and active case finding. In both endemic and non-endemic areas, the following strategies will be conducted:

Figure 17: Leprosy New Case and Cases on Register by end of Year, 1986-2012

57

a) Mapping of all leprosy cases diagnosed in the past two years to identify hot spots of transmission and to conduct contact tracing

b) Strengthening contact tracing in skin clinics by integrating leprosy screening activitiesc) Engaging and sensitizing CSOs implementing TB activities to integrate leprosy activities in their agenda.

In endemic areas: a) Tracing and screening of contacts of all children diagnosed with leprosy and adults in endemic areas b) Conducting dermatology polyclinics in endemic areasc) School contact tracing and educational campaigns to enhance detectiond) Integration of leprosy communication and active case finding material into the national community health service

kit.

Enhancing clinical care and rehabilitation

Enhancing clinical care and rehabilitation is core in leprosy elimination phase. Interventions will be implemented in both endemic and non-endemic areas. In both cases, there will be interventions aimed at:

a) Strengthening of linkages with local and international partners to ensure a continuous supply of MDTs and procurement and distribution of leprosy commodities, including MDT, auxiliary drugs for prevention and management of reactions

b) Mapping leprosy patient support groups and linking them to organizations that can help such groups to develop income generating activities

c) Engagement of skin experts in leprosy patient management and in mentoring health care workers on leprosy; e.g. Kenya Association of Dermatologist (KAD) and Kenya Association of Dermato-Venereology Officers (KDVO)

d) The national level will provide technical assistance to all counties.

In the five endemic areas, the strategic direction will focus on the following:

a) Training surgeons, medical and clinical officers and nurses on prevention of disabilities, rehabilitation and septic surgery

b) Training of physiotherapist, occupational therapist and social workers on leprosy rehabilitation c) Procurement of materials and equipment for patient’s rehabilitation, including crutches, other orthopedic

appliances and materials for their fabricationd) Reviving or integrating leprosy rehabilitative services in existing rehabilitative centers in the counties e) Training occupational therapists, physiotherapists, social workers and surgeons on rehabilitation of post-leprosy

disability management.

Strengthening monitoring and evaluation

In both endemic and non-endemic areas, recording and reporting will be strengthened through various approaches including:

a) Revision, printing and distribution of the existing data capture toolsb) Training of health care workers on the use of the recording and reporting tools and leprosy control indicatorsc) Revision of the leprosy module in TIBUd) Promotion of the inclusion of leprosy targets and M&E strategies within county health strategies and work plans e) Conducting a Leprosy KAP survey f) Undertaking operational research to assess the quality of care, including the patient perspective

In endemic areas:

a) Provide leprosy-specific mentorship, technical assistance and supportive supervision to the counties reporting leprosy casesb) The NTLD Program to dialogue with County Executives through various stakeholders’ forums to strategize on leprosy control at county levelsc) Engagement of clinicians belonging to the Kenya Association of Dermatologist (KAD) and Kenya Association of Dermato-Venereology Officers (KDVO) in mentoring health care workers on leprosy.

4.3.2.4. Leprosy

58

4.3.

2.4.

Lep

rosy

Contribution to NSP Impacts Outcomes (Leprosy)

Impact 3. Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy and lung diseases by 2018 (baseline TBD)

• Increase to at least 60% the proportion of eligible leprosy patients who access nutritional support, transport or financial subsidies, especially to facilitate diagnosis and treatment

Impact 4. Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018

• Increase the proportion of leprosy patients receiving rehabilitative services by 25%

• Increase by 10% the number of leprosy cases notified among children

• Increase to 85% the proportion of leprosy patients notified prior to grade 2 disability

Table 8: Impact and Outcome Indicators for Leprosy

59

Lepr

osy

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: Im

prov

ing

Publ

ic A

war

enes

s an

d Po

litic

al C

omm

itm

ent

1. N

umbe

r of

cou

ntie

s w

ith

lepr

osy

guid

elin

es in

pla

ce

2.

Num

ber

of

sens

itiz

atio

n m

eeti

ngs

for

lepr

osy

amon

g po

licy

mak

ers

cond

ucte

d

1. D

evel

op a

inv

estm

ent

man

ual

on

post

elim

inat

ion

2. C

ondu

ctin

g se

nsit

izat

ion

mee

ting

s on

lep

rosy

fo

r po

licy

mak

ers

and

st

akeh

olde

rs

1.

Hol

d a

5 da

y w

orks

hop

for

15 p

ax

outs

ide

nair

obi

to d

evel

op a

lep

rosy

po

st e

limin

atio

n in

vest

men

t m

anua

l

2. P

rint

and

dis

trib

ute

500

copi

es o

f the

le

pros

y po

st e

limin

atio

n m

anua

l

3. H

old

a 2

days

sen

siti

zati

on s

emin

ars

at

nati

onal

le

vel

fo

r st

akeh

olde

rs

and

Hea

lth

po

licy

mak

ers

fo

r 25

Pax

in

Nai

robi

to

dia

logu

e on

the

ro

adm

ap t

o l

epro

sy p

ost

elim

inat

ion

stra

tegi

es d

isce

min

ate

the

lepr

osy

post

el

imin

atio

n m

anua

l, c

omm

unic

ate

the

posi

tion

in

chan

ge i

n th

e H

ealt

h bi

ll an

d Pu

bic

Hea

lth

Act

and

adv

ocat

e fo

r re

leva

nt c

hang

es

0 1

1.

Con

duct

,

1 da

y co

unty

le

vel

stak

ehol

der

sens

itiz

atio

n m

eeti

ngs

for

30

Pax

each

on

le

pros

y

to

diss

emin

ate

th

e le

pros

y m

anua

l an

d ad

voca

te f

or

reso

urce

allo

cati

on

20 2

1. C

ondu

ct,

1 da

y 3

0 pa

x co

unty

le

vel

sta

keho

lder

mee

ting

to

revi

ew

the

lepr

osy

cont

rol

and

reso

urce

al

loca

tion

sit

uati

on in

the

6 e

ndem

ic

coun

ties

30 2

1. C

ondu

ct,

1 da

y 3

0 pa

x co

unty

lev

el

stak

ehol

der

mee

ting

to

re

view

th

e le

pros

y co

ntro

l an

d re

sour

ce a

lloca

tion

si

tuat

ion

in t

he 6

end

emic

cou

ntie

s

47 2

Stra

tegi

c A

ppro

ach

2: C

apac

ity

build

ing

of g

ener

al c

are

prov

ider

s

Prop

orti

on

of

coun

ties

bo

th

ende

mic

an

d no

n en

dem

ic

repo

rtin

g ne

w

lepr

osy

case

s pr

esen

ting

wit

h di

sabi

lity

grad

e 2

1. C

ondu

ct

a na

tion

al T

OT

trai

ning

(t

o tr

ain

coun

ty

ToTs

on

le

pros

y)

2. C

ondu

ct t

rain

ings

for

hea

lth

care

w

orke

rs a

t th

e co

unty

leve

l

3. S

ensi

tiza

tion

mee

ting

s to

CH

WS

4.

Spon

sor

offi

cers

fo

r le

pros

y co

urse

s

5.

Ref

resh

er c

ours

es f

or L

ab s

taff

on

skin

slit

sm

ear

and

bact

erio

logi

cal

diag

nosi

s.

1.

Con

duct

tw

o ce

ntra

l tr

aini

ng

for

Cou

nty

and

nati

onal

TOT

Trai

ning

: 25

pax

each

fro

m e

ndem

ic a

reas

and

na

tion

al le

vel

2.Sp

onso

r 2

Surg

eons

fo

r Re

cons

truc

tive

cou

rse

3. T

o sp

onso

r tw

o le

pros

y of

fice

rs( O

ne

Nat

iona

l, on

e C

ount

y) t

o at

tend

the

le

pros

y ad

vanc

e co

urse

in A

LERT

4. T

rain

180

pax

of

HC

Ws

on l

epro

sy

diag

nosi

s an

d m

anag

emen

t in

6

ende

mic

are

as

5. H

old

CH

Ws

Sens

itiz

atio

n m

eeti

ng o

f 12

0 Pa

x pe

r C

ount

y in

end

emic

are

as

6.

Trai

n

50

CH

EWs

pe

r en

dem

ic

Cou

nty

on

lepr

osy

7. C

ondu

ct r

efre

sher

tra

inin

g to

30

lab.

st

aff i

n en

dem

ic a

reas

on

slit

ski

n sm

ear

and

bact

erio

logi

cal d

iagn

osis

30%

1.Tr

ain

100

pax

(HC

Ws)

on

lepr

osy

diag

nosi

s an

d m

anag

emen

t in

en

dem

ic

area

s an

d 15

0 i

n no

n- e

ndem

ic a

reas

fo

r 3

days

2.

Hol

d 2

CH

Ws

Sens

itiz

atio

n m

eeti

ng f

or 3

0 Pa

x in

end

emic

ar

ea

and

4 no

n-

ende

mic

re

port

ing

area

s

25%

1.Tr

ain

100

pax

(HC

Ws)

on

lep

rosy

di

agno

sis

and

man

agem

ent

in

ende

mic

ar

eas

and

150

in

no

n-

ende

mic

are

as f

or 3

day

s

2.

Hol

d 2

CH

Ws

Sens

itiz

atio

n m

eeti

ng f

or 3

0 Pa

x i

n en

dem

ic a

rea

and

4 no

n- e

ndem

ic r

epor

ting

are

as.

20%

1.Tr

ain

100

pax

(HC

Ws)

on

lepr

osy

diag

nosi

s an

d m

anag

emen

t in

end

emic

ar

eas

and

150

in

non-

end

emic

are

as

for

3 da

ys

2. H

old

2 C

HW

s Se

nsit

izat

ion

mee

ting

fo

r 30

Pax

in

ende

mic

are

a an

d 4

non-

en

dem

ic r

epor

ting

are

as.

15%

Stra

tegi

c A

ppro

ach

3: L

epro

sy s

urve

illan

ce a

nd a

ctiv

e ca

se f

indi

ng

A

func

tion

al

surv

eilla

nce

syst

em

repo

rtin

g on

all

lepr

osy

indi

cato

rs1.

Con

duct

con

sult

ativ

e w

orks

hop

to d

evel

op a

sur

veill

ance

sys

tem

on

lepr

osy

and

ref

er f

or d

iagn

osis

2. P

rocu

re l

ab c

onsu

mab

les

for

SSS

&H

isto

logi

es

3. C

ondu

ct O

pera

tion

al r

esea

rch

1.

Map

ping

ou

t of

al

l le

pros

y ca

ses

diag

nose

d in

the

pas

t 2

year

s (2

013/

14)

and

cond

ucti

ng c

onta

ct t

raci

ng

2.

To o

rgan

ize

and

cond

uct

a 5

day

cons

ulta

tive

for

um t

o re

view

map

ping

re

sult

s an

d de

velo

p a

surv

eilla

nce

syst

em

11.

C

ondu

ct

cont

act

trac

ing

of

all

inde

x ca

ses

in

all

coun

ties

re

port

ing

new

cas

es.

2. C

ondu

ct O

R on

qua

lity

of c

are

of

pati

ents

re

ceiv

ing

lepr

osy

serv

ices

3.

Mal

nutr

itio

n le

vels

am

ong

lepr

osy

pati

ents

det

erm

ined

1Re

view

w

orks

hop

to

eval

uate

pe

rfor

man

ce o

f th

e sy

stem

1

1. V

alid

atio

n of

lepr

osy

data

for

the

NSP

pe

riod

2.

Doc

umen

tati

on

lepr

osy

part

ners

for

th

e 4

year

per

iod

1

4.3.2.4. Leprosy

4.3.

2.4.

Lep

rosy

Lepr

osy

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on o

f le

pros

y re

ferr

ed f

or

scre

enin

g fr

om c

omm

unit

y

1.

Con

tact

tr

acin

g ac

tivi

ties

at

co

mm

unit

y le

vel

2.

Faci

litat

e ex

amin

atio

n of

sk

in

patc

hes

and

refe

rals

1.

Sens

itiz

e an

d su

ppor

t C

SOs

impl

emen

ting

EN

GA

GE

TB a

ctiv

itie

s t

o in

tegr

ate

lepr

osy

in t

heir

pro

gram

s

2.

Hol

d se

nsit

izat

ion

mee

ting

s fo

r C

HW

s to

inc

lude

scr

eeni

ng f

or l

epro

sy

duri

ng h

ouse

-to-

hous

e ca

mpa

igns

3.

To

cond

uct

hous

e-to

-hou

se

scre

enin

g fo

r s

kin

lesi

ons

4.

C

ondu

ct

rout

ine

‘SK

IN

Patc

h'

exam

inia

tion

on

all p

atie

nts

pres

enti

ng

wit

h hy

popi

gmen

ted

skin

pat

ches

5.

Con

duct

ing

Slit

ski

n sm

ears

tes

ts

in p

atie

nts

pres

enti

ng w

ith

susp

ecio

us

skin

le

ssio

ns

bu

t

wit

hout

le

pros

y ca

rdin

al s

igns

labo

rato

ries

6. T

rain

ing

of h

ealt

h ca

re w

orke

rs

at

coun

ty l

evel

to

incr

ease

the

ir l

evel

of

susp

ecio

n of

lepr

osy

7.

Refe

rral

of

pr

esum

ptiv

e le

pros

y ca

ses

for

scre

enin

g

70%

1.

CH

Ws

to

cond

uct

hous

e-to

-ho

use

scr

eeni

ng f

or s

kin

lesi

ons

2.

Con

duct

ro

utin

e ‘S

KIN

Pa

tch’

ex

amin

iati

on

on

all

pati

ents

pr

esen

ting

w

ith

atyp

ical

pr

esen

tati

ons(

ca

rdin

al

sign

s un

clea

r)

in

all

faci

litie

s w

ithi

n en

dem

ic

site

s

3.

C

ondu

ctin

g Sl

it

skin

sm

ears

te

sts

done

in C

ount

y la

bora

tori

es

4. T

rain

ing

of h

ealt

h ca

re w

orke

rs

at c

ount

y le

vel

to i

ncre

ase

thei

r le

vel o

f su

spic

ion

of le

pros

y

5. R

efer

ral o

f pr

esum

ptiv

e le

pros

y ca

ses

for

scre

enin

g

80%

1.

Con

duct

ho

use-

to-h

ouse

sc

reen

ing

for

ski

n le

sion

s

2.

Con

duct

ro

utin

e ‘S

KIN

Pa

tch’

ex

amin

iati

on

on

all

pati

ents

w

ith

atyp

ical

pr

esen

tati

ons

in

all

faci

litie

s w

ithi

n en

dem

ic

site

s

3.

Con

duct

ing

Slit

ski

n sm

ears

tes

ts

done

in C

ount

y la

bora

tori

es

4.

Tra

inin

g of

hea

lth

care

wor

kers

at

co

unty

leve

l to

incr

ease

the

ir le

vel o

f su

spic

ion

of le

pros

y

5.

Re

ferr

al

of

pres

umpt

ive

lepr

osy

case

s fo

r sc

reen

ing

90%

1. C

ondu

ct h

ouse

-to-

hous

e s

cree

ning

for

skin

lesi

ons

2.

C

ondu

ct

rout

ine

‘SK

IN

Patc

h'

exam

inia

tion

on

all

pati

ents

pre

sent

ing

wit

h at

ypic

al

pres

enta

tion

s(

card

inal

si

gns

uncl

ear)

in

al

l fa

cilit

ies

wit

hin

ende

mic

sit

es

3. C

ondu

ctin

g Sl

it s

kin

smea

rs t

ests

don

e in

Cou

nty

labo

rato

ries

4.

Trai

ning

of

he

alth

ca

re

wor

kers

at

co

unty

lev

el t

o in

crea

se t

heir

lev

el o

f su

spec

ion

of le

pros

y

5.

Ref

erra

l of

pre

sum

ptiv

e le

pros

y ca

ses

for

scre

enin

g

100%

Prop

orti

on o

f pl

anne

d sc

hool

he

alth

pro

gram

s co

nduc

ted

Scho

ol h

ealt

h pr

ogra

ms:

con

duct

he

alth

edu

cati

on in

sch

ools

in

ende

mic

are

as e

very

qua

rter

on

lepr

osy

Con

duct

hea

lth

educ

atio

n in

sc

hool

s in

end

emic

are

as e

very

qu

arte

r on

lepr

osy

100%

Con

duct

hea

lth

educ

atio

n in

sch

ools

in

end

emic

are

as e

very

qua

rter

on

lepr

osy

100%

Con

duct

hea

lth

educ

atio

n in

sch

ools

in

ende

mic

are

as e

very

qua

rter

on

lepr

osy

10

0%

Prop

otio

n of

sc

hool

s in

en

dem

ic

area

s in

w

hich

ch

ildre

n w

ere

scre

ened

for

lepr

osy

Con

duct

sch

ool h

ealt

h pr

ogra

m a

nd

scre

enin

g fo

r le

pros

yTr

aini

ng o

f sc

hool

goi

ng c

hild

ren

on

and

scre

enin

g

for

skin

pa

tche

s in

sc

hool

s n

eigh

bour

ing

a ho

mes

tead

of

a n

ew le

pros

y c

ase

1. S

ensi

tiza

tion

mee

ting

s (2

0 pa

x)

for

Com

mun

ity

heal

th c

omm

itee

in

all

6 en

dem

ic a

reas

2.

Con

duct

15

pu

blic

Ba

rasa

m

eeti

ngs

per

Cou

nty

in

each

en

dem

ic a

reas

per

yea

r

3.

Trai

ning

of

sc

hool

go

ing

child

ren

on a

nd s

cree

ning

for

ski

n pa

tche

s in

sch

ools

nei

ghbo

urin

g a

hom

este

ad o

f a

ne

w l

epro

sy

case

100%

1. C

ondu

ct 1

5 pu

blic

Bar

asa

mee

ting

s in

end

emic

are

as

2. C

ondu

ct s

choo

l he

alth

edu

cati

on

and

scre

enin

g in

20

scho

ols

in e

ach

ende

mic

are

a.

100%

1. C

ondu

ct 1

5 pu

blic

Bar

aza

mee

ting

s in

en

dem

ic a

reas

2.

Con

duct

sch

ool

heal

th e

duca

tion

and

sc

reen

ing

in 2

0 sc

hool

s in

eac

h en

dem

ic

area

.

100%

Stra

tegi

c A

ppro

ach

4: E

nhan

cing

clin

ical

car

e an

d re

habi

litat

ion

1. P

ropo

rtio

n of

pol

y sk

in c

linic

s co

nduc

ted

in t

he e

ndem

ic c

ount

ies

per

quar

ter

2. P

ropo

rtio

n of

lep

rosy

pat

ient

s w

ho a

re m

alno

uris

hed

who

rec

eive

th

erap

euti

c fo

od

1.

Dev

elop

men

t of

trea

tmen

t m

anua

l

2.

Reno

vati

on

and

equi

ping

of

re

gion

al

spec

ialis

ed

cent

re

to

impr

ove

clin

ical

car

e

3.

Prov

ide

ther

apeu

tic

feed

to

m

alno

uris

hed

pati

ents

1. T

o c

ondu

ct a

5

days

wor

ksho

p to

de

velo

p a

lepr

osy

post

el

imin

atio

n m

anua

l

2.

To

orie

ntat

e th

e ph

ysio

an

d oc

cupa

tion

al t

hera

pist

in

the

iden

tifi

ed

faci

litie

s on

m

anag

emen

t an

d re

habi

litat

ion

of le

pros

y pa

tien

ts

3.

Ass

essm

ent

and

iden

tifi

cati

on

of

appr

opri

ate

fa

cilit

ies

to

prov

ide

reha

bilit

ativ

e se

rvic

es

4.

Proc

urem

ent

of

mat

eria

ls

and

equi

pmen

ts

5.

Li

nk

mal

nour

ishe

d pa

tien

t w

ith

nutr

itio

n cl

inic

for

the

rape

utic

fee

ds

30%

N/A

1.

Con

duct

Po

ly

skin

cl

incs

in

en

dem

ic a

res

on q

uart

erly

bas

is

2.

Act

ive

cont

act

trac

ing

3.

Ass

essm

ent

and

iden

tifi

cati

on

of a

ppro

pria

te fa

cilit

ies

to p

rovi

de

reha

bilit

ativ

e se

rvic

es

4. P

rocu

rem

ent

of m

ater

ials

and

eq

uipm

ents

5. L

ink

mal

nour

ishe

d pa

tien

t w

ith

nutr

itio

n cl

inic

fo

r th

erap

euti

c fe

eds

60%

30%

1.

Con

duct

Po

ly

skin

cl

incs

in

en

dem

ic a

res

on q

uart

erly

bas

is

2. A

ctiv

e co

ntac

t tr

acin

g

3.

Ass

essm

ent

and

iden

tifi

cati

on

of a

ppro

pria

te

faci

litie

s to

pro

vide

re

habi

litat

ive

serv

ices

4.

Proc

urem

ent

of

mat

eria

ls

and

equi

pmen

ts

5.

Link

m

alno

uris

hed

pati

ent

wit

h nu

trit

ion

clin

ic f

or t

hera

peut

ic f

eeds

80%

60%

1. C

ondu

ct P

oly

skin

clin

cs i

n en

dem

ic

ares

on

quar

terl

y ba

sis

2. A

ctiv

e co

ntac

t tr

acin

g

3.

Ass

essm

ent

and

iden

tifi

cati

on

of

appr

opri

ate

fa

cilit

ies

to

prov

ide

reha

bilit

ativ

e se

rvic

es

4.

Proc

urem

ent

of

mat

eria

ls

and

equi

pmen

ts

5.

Link

m

alno

uris

hed

pati

ent

wit

h nu

trit

ion

clin

ic f

or t

hera

peut

ic f

eeds

100%

100%

Lepr

osy

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

5: S

tren

gthe

ning

mon

itor

ing

and

eval

uati

on

Prop

orti

on

of

coun

ties

bo

th

ende

mic

an

d no

n en

dem

ic

repo

rtin

g ti

mel

y an

d co

mpl

etel

y on

lepr

osy

1. U

pdat

ing

syst

em o

n le

pros

y

2. C

ondu

ct o

pera

tion

al r

esea

rch

1. U

pdat

ing

TIBU

sys

tem

to

accu

rate

ly

reco

rd d

isab

ility

gra

ding

80%

1.

Revi

sion

, pr

inti

ng

and

dist

ribu

tion

of

the

exis

ting

dat

a ca

ptur

e to

ols

2. T

rain

ing

of h

ealt

h ca

re w

orke

rs

on

the

use

of

the

reco

rdin

g an

d re

port

ing

tool

s an

d le

pros

y co

ntro

l ind

icat

ors

3. R

evis

ion

of t

he le

pros

y m

odul

e in

TIB

U

4.

Prom

otio

n of

th

e in

clus

ion

of

lepr

osy

targ

ets

and

M&

E st

rate

gies

w

ithi

n co

unty

he

alth

st

rate

gies

and

wor

k pl

ans

5. L

epro

sy K

AP

sur

vey

will

be

cond

ucte

d

6. O

R on

qua

lity

of c

are

(fro

m

the

eye

of

the

Pati

ent)

to

be

co

nduc

ted

85%

On

job

trai

ning

on

use

of d

ata

tool

s an

d on

pro

pmt

repo

rtin

g90

%1.

Pri

ntin

g an

d di

stri

buti

on o

f the

exi

stin

g da

ta c

aptu

re t

ools

2. O

n jo

b tr

aini

ng o

f ne

w h

ealt

h ca

re

wor

kers

on

the

use

of t

he r

ecor

ding

and

re

port

ing

3. O

R on

qua

lity

of c

are

(fro

m t

he e

ye o

f th

e Pa

tien

t) t

o be

con

duct

ed

4. K

AP

surv

ey o

n le

pros

y co

nduc

ted

>95

%

4.3.2.4. Leprosy

4.3.3. Engage All Care Providers - PPM1. Situational Analysis

Kenya has been a frontrunner in the implementation of the 4th component of the STOP TB strategy: Engaging All Care Providers. The non-state or private health care sector collectively provides almost 50% of all health care provided to Kenyans.

The range of providers in this sector is wide, extending from large health institutions that offer state of the art health care services to informal providers, some of whom are not approved by relevant regulatory bodies. The private sector in Kenya has both private not-for-profit and private self-financing sectors. The private not-for-profit includes faith-based (FBO) and non-governmental organizations (NGOs). They are the second largest providers of health services in Kenya after the public sector. The government supports most of the FBO/NGO-based health care facilities.

The FBO/NGO network of health care facilities has long been part of the network of TB service providers supported by the NTLD Program. Public-private mix (PPM) activities will target the inclusion of the private self-financing sector.

Kenya has been implementing a PPM initiative involving the private self-financing sector for over 15 years. The total number of cases notified from this sector rose from 7,160 in 2010 to 11,000 in 2012, representing 19% of total cases notified by the NTLD Program. The treatment success rate for new smear positive patients rose from 83% in 2010 to 88% in 2012. Though it is implemented in almost all counties in the country, the initiative is currently most vibrant in 15 urban centers in Kenya. About 255 private health facilities are included along with 185 private laboratories that are linked to the national public sector-led external quality assurance system for TB bacteriology. Currently, out of the 245 laboratories involved in PPM, only 75% are linked to the national EQA system. Therefore, the engagement of private health care providers and especially solo private providers remains a challenge.

In addition to the conventional private sector, other players, such as the corporate sector, traditional healers, herbalists and faith healers who interact with TB patients, need to be engaged. There is an opportunity to involve all these providers in TB control.

2. Strategic Direction(s) for 2015-2018

The priority is to scale-up the number and diversity of private sector actors engaged in quality TB case detection and management.

4.3.

3. E

ngag

e A

ll Ca

re P

rovi

ders

(PPM

)

63

Map 7: Distribution of Private Providers Notifying Cases by Population Density, 2013

Proposed Approaches

The approaches for engaging all health care providers include sustaining the capacity of those that are already engaged and extending the network of quality-assured actors to those that are not yet engaged in TB control activities.

Currently, PPM is being implemented in health facilities in urban areas of 14 counties. In these counties, the priority will be to ensure the continued quality of care through the private sector. PPM activities will be scaled up in the other 33 counties through a step-wise approach. Specific activities include:

a) Sustain the gain in areas where PPM is currently being implemented

i. Refresher training and on-the-job tools to support sustained capacity among health care workers engaged in PPM

a. undertake task-specific training, determined by cadre of health care provider, using the ISTC training materials and national TB/HIV training manual

b. Develop a web based training using the ISTC training materials and other TB/HIV training manuals c. Develop appropriate mechanisms to evaluate the training to different cadres of health care workers

ii. Support symposia, special sessions, workshops and other relevant forums at the annual scientific conferences of professional associations, including KMA, KPA, KAPT, KCOA, NNAK and PSK, and to reach individual members of these associations with TB task-specific messages

iii. Provide regular technical assistance by county TB and leprosy coordinators to link private providers to NTLD Program implementing facilities and ensure quality

iv. Identify and strengthen capacity for PMDT in at least one private health facility in each of the DR-TB high burden counties

v. Intensify the engagement of private-sector laboratories, including:a. Technical assistance on TB bacteriology to private laboratoriesb. Linkages between the public and private health facilitiesc. Networking of laboratories to the national EQA system d. Engaging a pool of TB laboratory experts to support establishment of new diagnostic sites through the PPL

taskforce

4.3.3. Engage All Care Providers (PPM

)

64

Figure 18: Private Sector Contribution to Indentification of TB Patients, 2013

e. Promoting referral of TB specimens between sectors

vi. Increase reporting by the private sector through dissemination of paper-based tools and capacity building for wider use of TIBU; incorporate private providers in NTLD Program data quality audits, capacity building for M&E, and use of data for decision-making.

b) Scale-up the number and diversity of private providers contributing to TB control activities, in all counties

i. Map all care providers in each county and prioritize new partners to engage, based on geographic coverage and potential to provide quality service

ii. Establish national guidance on the functions expected for various cadres of private providers

iii. Establish MOUs between the care providers and appropriate level of the NTLD Program (national, county or sub-county); provide technical assistance to facilities to organize the incorporation of quality TB, leprosy and lung health services

iv. Ensure availability of commodities and M&E tools for assessing progress around TB, leprosy and lung diseases

v. Revise, disseminate and distribute the PPM policy guidelines.

c) Strengthen coordination mechanisms for PPM at the national and county levels

i. Strengthen the national steering team /technical working group (TWG) on PPM and promote county-level TWGs

ii. Identify county level PPM focal person(s), and define functions to support PPM

iii. Hold an annual national PPM workshop to disseminate PPM

norms and standards, practices, reporting systems and review progress

iv. Hold annual regional PPM workshops to sensitize regional TB control teams on PPM norms and standards, practices, reporting systems and review progress

v. Establish a multi-sectoral collaboration forum with other ministries (e.g. Ministry of Environment, Water and Natural Resources; Ministry of Labor, Social Security and Services; Ministry of Education; Ministry of Land, Housing and Urban Development; and Ministry of Sports, Culture and the Arts), the health and non-health private sector players, health professional organizations, training institutions etc.

d) Ensure quality of PPM activities for TB, leprosy and lung disease

i. Identify centers of excellence in PPM from the 14 established counties to provide on-site mentorship, training and technical assistance to new sites. Establish a roster of experts/consultants at national and county level to provide mentorship in the private sector

ii. Empower regional TB, leprosy and lung disease coordinators to provide supervision and monitoring of services in the private sector

4.3.

3. E

ngag

e A

ll Ca

re P

rovi

ders

(PPM

)

Non-state providers to be targeted

• Private for-profit or self-financing hospitals: Health institutions that offer services similar to what is offered in national referral hospital or more

• Corporate Health Services: A number of corporate organizations provide health care services at the workplace or other site for their workers and their dependents. A range of other workplace TB care programs have been initiated and will be scaled up. These include training and support of peer educators, active screening of workers for TB, workplace treatment support for patients on TB medications and other activities

• Individual private for-profit health care providers (solo providers): This group comprises of medical doctors, clinical officers, nurses, medical laboratory technologists and others. A mapping exercise carried out in 20 urban areas in 2011 came up with a total of 1,745 providers, of which 45% were solo providers. Most of the solo private health providers of all cadres are concentrated in urban areas

• Retail pharmacies, chemists and drug shops: These are found in both urban and rural areas. These tend to be the first point of contact for patients, including TB patients, and can be networked for referral of presumptive TB cases

• Informal Care Providers: These include, but are not limited to, traditional healers and herbalists, faith healers, home-based care groups providing care to HIV positive patients and other health volunteers.

Box 4

65

iii. Ensure involvement of all private health providers in quality improvement activities, such as continuous quality improvements (CQIs) and data quality assessments (DQA), to improve the surveillance of TB, leprosy and lung diseases from the private sector

iv. Enforce mechanism for ensuring the government is notified of all TB patients

v. Assess the availability of anti-TB drugs in retail pharmacies and chemists; develop and enforce appropriate regulations to restrict and promote rational use of anti-TB drugs that become available through the retail pharmacies and chemists.

Contribution to NSP Impacts Outcomes (PPM)

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

• Increase case notification by the private and non-state sectors by 25% • Ensure treatment success of at least 90% of all DS TB patients managed by private providers

Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15%, by 2018

• Ensure treatment success of at least 80% of MDR-TB patients managed by private providers

Impact 2: Reduce mortality due to TB by 3% by 2018 • Ensure treatment success of at least 90% of all DS TB patients managed by private providers• Reduce deaths among HIV-infected TB patients man-aged by private providers to 5% or lower

Impact 3. Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy and other lung diseases, by 2018

• Introduce reimbursements for TB-related expenses in all private and public health insurance schemes

Impact 4. Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018

• Increase to 90% the proportion of patients notified by the private sector prior to grade 2 morbidity

Table 9: Impact and Outcome Indicators for PPM

4.3.3. Engage All Care Providers (PPM

)

66

Enga

ging

All

Car

e Pr

ovid

ers

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1; S

usta

in t

he g

ains

in a

reas

whe

re P

PM is

cur

rent

ly b

eing

impl

emen

ted

Num

ber

of

HC

Ws

trai

ned

on

TB/H

IV,

PMD

T,

Paed

iatr

ic T

B, P

AL

Trai

n H

CW

s o

n TB

usi

ng t

he n

atio

nal

TB/H

IV c

urri

cullu

m (1

5 co

unti

es)

n/a

5 tr

aini

ngs

150

5 tr

aini

ngs

150

5 tr

aini

ngs

150

Trai

n

HC

Ws

on

M

DR-

TB

us

ing

the

nati

onal

D

R-TB

cu

rric

ullu

m

(15

coun

ties

)

n/a

5 tr

aini

ngs

150

5 tr

aini

ngs

150

5 tr

aini

ngs

150

Trai

n H

CW

s o

n Pe

d TB

us

ing

the

nati

onal

cur

ricu

llum

( 5

coun

ties

)n/

a5

trai

ning

s 15

05

trai

ning

s 15

05

trai

ning

s 15

0

Trai

n H

CW

s o

n PA

L u

sing

the

nati

onal

cu

rric

ullu

m (1

5 co

unti

es)

n/a

5 tr

aini

ngs

150

5 tr

aini

ngs

150

5 tr

aini

ngs

150

Num

ber

of c

onfe

renc

es w

ith

TB s

ympo

sia

held

at

ann

ual

scie

ntif

ic c

onfe

renc

es o

f pr

ofes

sion

al

asso

ciat

ions

Supp

ort

sym

posi

a an

d sp

ecia

l ses

sion

s on

TB

at

the

annu

al

scie

ntif

ic

conf

eren

ces

of

prof

essi

onal

as

soci

atio

ns

incl

udin

g K

MA

, K

PA,

KA

PT,

KC

OA

, N

AK

, PS

K,

to

reac

h in

divi

dual

m

embe

rs

of

thes

e as

soci

atio

ns

wit

h TB

ta

sk

spec

ific

m

essa

ges

n/a

1/2

day

sym

posi

a in

six

con

fere

nces

61/

2 da

y sy

mpo

sia

in s

ix c

onfe

renc

es6

1/2

day

sym

posi

a in

si

x co

nfer

ence

s6

Num

ber

of f

acili

ty d

ialo

gue

mee

ting

s he

ld w

ith

priv

ate

heal

th f

acili

ty m

anag

ers

and

staf

fH

old

dial

ogue

m

eeti

ngs

wit

h 85

pr

ivat

e he

alth

fac

ility

man

ager

s an

d st

aff

to

desi

gn a

nd im

plem

ent

faci

lity

spec

ific

TB

and

TB/H

IV s

ervi

ce (

appr

ox

10 s

taff

per

fac

ility

)

10 d

ialo

gue

mee

ting

s he

ld a

t se

lect

ed f

acili

ties

10

25

dial

ogue

m

eeti

ngs

at

sele

cted

fa

cilit

ies

2525

di

alog

ue

mee

ting

s at

se

lect

ed

faci

litie

s25

25

dial

ogue

m

eeti

ngs

at

sele

cted

fac

iliti

es25

Num

ber

of s

uper

visi

on v

isit

s to

pri

vate

fac

ility

/cl

inic

ow

ners

Prov

ide

TA

(Sub

C

TLC

s,

PPM

C

oord

inat

ors)

to

priv

ate

faci

lity/

clin

ic

owne

rs

Hol

d qu

arte

rly

supp

orti

ve

supe

rvis

ion

in a

ll 25

51,

020

Hol

d qu

arte

rly

supp

orti

ve

supe

rvis

ion

in a

ll 25

51,

020

Hol

d qu

arte

rly

supp

orti

ve

supe

rvis

ion

in a

ll 25

51,

020

Hol

d qu

arte

rly

supp

orti

ve

supe

rvis

ion

in a

ll 25

51,

020

Num

ber o

f cou

ntie

s of

fere

d te

chni

cal a

ssis

tanc

e by

na

tion

al t

eam

Prov

ide

Tech

nica

l su

ppor

t/

supp

ort

supe

rvis

ion

by n

atio

nal l

evel

tea

mIn

tegr

ated

mis

sion

for

pri

vate

fa

cilit

y su

perv

isio

n ye

arly

in

15 c

ount

ies

15In

tegr

ated

mis

sion

for p

riva

te fa

cilit

y su

perv

isio

n ye

arly

in 1

5 co

unti

es15

Inte

grat

ed

mis

sion

fo

r pr

ivat

e fa

cilit

y su

perv

isio

n ye

arly

in

15

co

unti

es

15In

tegr

ated

mis

sion

for

pri

vate

fa

cilit

y su

perv

isio

n ye

arly

in

15 c

ount

ies

15

Num

ber

of p

riva

te H

CW

s se

nsit

ized

on

reco

rdin

g &

rep

orti

ngSu

ppor

t t

he n

atio

nal

TB s

urve

illan

ce

syst

em a

mon

g pr

ivat

e pr

ovid

ers

Con

duct

one

day

sen

siti

zati

on

mee

ting

s on

dat

a co

llect

ion

tool

s ta

rget

ting

30

he

alth

ca

re p

rovi

ders

fr

om p

riva

te

DO

T fa

cilit

ies

30C

ondu

ct

one

day

sens

itiz

atio

n m

eeti

ngs

on

data

co

llect

ion

tool

s ta

rget

ting

90

heal

th p

rovi

ders

fr

om

priv

ate

DO

T fa

cilit

ies

90C

ondu

ct

one

day

sens

itiz

atio

n m

eeti

ngs

on d

ata

colle

ctio

n to

ols

targ

etti

ng 9

0 he

alth

pro

vide

rs f

rom

pr

ivat

e D

OT

faci

litie

s

90C

ondu

ct o

ne d

ay s

ensi

tiza

tion

m

eeti

ngs

on d

ata

colle

ctio

n to

ols

targ

etti

ng

90

heal

th

prov

ider

s f

rom

pri

vate

DO

T fa

cilit

ies

90

Num

ber

of p

riva

te f

acili

ties

tra

ined

to

use

data

fr

om r

ecor

ding

& r

epor

ting

Supp

ort

2 da

y da

ta

feed

back

/CQ

I fo

rum

s (h

ealt

h ca

re

prov

ider

s an

d TB

co

ordi

nato

rs)

in 1

5 co

unti

es

bi a

nnua

lly.

(C

ount

y cl

uste

ring

3 c

ount

ies

per

mee

ting

, 5 m

eeti

ngs

wit

h 45

pax)

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Map

of

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ate

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3. E

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rovi

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(PPM

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ount

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a

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ties

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ith

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emin

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PPM

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d di

ssem

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ion

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s fo

r PP

M p

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cum

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32

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d di

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3: S

tren

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nati

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echa

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s fo

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e na

tion

al a

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vels

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ber

of T

WG

mee

ting

s he

ldSu

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the

nat

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l PPM

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tely

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nat

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Num

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of

annu

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annu

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M

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alit

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ivit

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for

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ng d

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th a

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vate

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4.3.3. Engage All Care Providers (PPM

)

4.3.4. Promote and strengthen community engagement and build national commitment to TB, leprosy and lung disease

1. Situational Analysis

In 2013, the NTLD Program Annual Report indicated that 3,255 (4%, n=89,760) TB patients reached health facilities through referrals from community approaches, specifically CHWs, and 883 TB patients (1%, n=89,760) received treatment in the community, (map 8). Only 6 counties had more than 9% of cases referred by the community.

In the Kenya Health Policy Framework 2012-30, the community is recognized as a level of health service delivery (Tier 1). This policy boosts Kenya’s focus on the role of community participation in health and general socio-economic development actions. At community level, platforms exist which can be utilized for implementation of systematic contact investigation, referrals between health facilities and community members, as well as promotion of adherence to treatment.

In 1998, community-based TB care (CBTC) was launched nationally with the introduction of community health workers for case finding, case holding and health promotion activities in collaboration with the MOH. In 2006, the MOH developed a community health strategy to enable health service delivery at

4.3.

4. C

omm

unit

y En

gage

men

t

Map 8: % of Community-Referred Cases among All Case Notifications

Figure 19: Community Contribution to Identification of TB Patients, 2013

69

the household and community level through the introduction of 6,000 community units. The plan aimed to link each community program to a health facility under the management of a Community Health Extension Worker (CHEW), covering a population of 1,000 individuals and 25 community health workers (CHWs). In 2012, a national TB Civil Society Organzations (CSOs) coordination forum was established.

There are now 2,943 Community Health Units (CHUs) established across the country, although only 1,587 are fully functional. Figure 19 shows community-referred case notification, highlighting strong community contributions to case notification particularly in some urban areas, providing models of success upon which further expansion can be based.

The Ministry of Health, through the Community Health Services Program (CHS-Program) and the NTLD Program, together with development and implementing partners, have developed policies, guidelines and training manuals to harmonize the engagement and implementation of TB, leprosy and lung diseases activities at community level.

Two community-based care models were established in 1998 and 2010 respectively (see lessons learned).

Documentation of community TB interventions including presumptive TB screening and food security at community level are not yet incorporated into the systemic monitoring and evaluation of the NTLD Program. A mechanism for retrieval of treatment interrupters is in place but these efforts are not captured in the e-reporting (TIBU) system.

A national communication strategy exists and an advocacy strategy is still in its draft form. These two documents have not yet been fully disseminated and are underutilized at the community level.

2. Strategic Direction(s) for 2015-2018

To optimize the use of community-level platforms for TB, leprosy and lung health, priority will be given to broadening and diversifying the array of partners at community level who incorporate TB, leprosy and lung health into their priorities, especially in areas with low levels of community-referred TB cases at present and in areas endemic to leprosy. Secondly, this plan aims to empower community-level partners and populations to develop and implement locally-relevant solutions to delayed case finding, morbidity and poor treatment outcomes.

3. Proposed Approaches

4.3.4. Comm

unity Engagement

Box 5

Lessons Learned

Improved treatment adherence utilizing community health workers1

A retrospective cohort study of patients registered for treatment between the periods 2005 to 2011 was conducted. 54% of the reviewed 2,778 TB patients utilized a Community Health Worker. Adherence was shown to be higher in patients who utilized CHW, especially in urban settings.

ENGAGE-TB

The Engage-TB Model brings on board health and non-health stakeholders that have not previously been involved in TB management. Its operational guidance and policies support NGOs/CSOs to integrate TB into their community-based work in sectors such as maternal, newborn and child health (MNCH), HIV care, primary health care (PHC), education, agriculture and livelihoods development programmes.

Other innovations in pilot phase

a) Livelihood and food security initiatives for eligible TB patients. MDR-TB patient support, including food support, in place through AMPATH

b) Use of mobiles technology platforms to send SMS reminders for TB clinic attendance (AMPATH)

c) Existence of psychosocial support groups for TB e.g. TB clubs, TB Ambassadors, TB Pamoja, Kinunga, Waso, Kibera Post Test

d) Health education forums - through barazas and radio programs, annual national events i.e. World TB Day

Build the foundation for systematic community and partner engagement

a) Identify opportunities for expansion of proven models: conduct mapping of community platforms and partners that may reach populations in need of TB, leprosy and lung health services. Examples include other health and development related programs such as nutrition and MNCH programs. Emphasis will be given to mapping areas with low community engagement.

b) Build a web of community organizations linked to the NTLD Program: Develop MoUs between NTLD Program or county health offices and CSOs, NGOs and community partners to define roles, responsibilities and resources. Use MoUs

_______________________________________________________________________________________________________________________________1 EOng’ang’o JR, Mwachari C, Kipruto H, Karanja S (2014) The Effects on Tuberculosis Treatment Adherence from Utilising Community Health Workers: A

Comparison of Selected Rural and Urban Settings in Kenya. PLoS ONE 9(2): e88937. doi:10.1371/journal.pone.0088937

70

to connect community-level actors to service delivery points for mentorship, monitoring and support.

c) Enhance capacity at community level: Develop a capacity building plan for CTBC, based on needs and capacities of newly identified community-level partners. Engage the implementers of successful models as Centers of Excellence, for on-site mentoring and training.

d) Engage communities and counties in planning: Include community stakeholders in coordination, annual planning, implementation, monitoring, and evaluation of activities at national and county level. Ensure NTLD Program participation in county health and NGO forums. Support county coordination committees to oversee implementation of community engagement and communication activities. Organize forums with governors to advocate for resource allocation for community based TB and Leprosy activities.

e) Create patient engagement guidelines and update other policy tools.

f) Actively participate in the harmonization of payment levels of CHWs across programs according to MoH guidelines.

Operationalize patient-centered care through community structures, scaling up proven community-based models

a) Train, mentor and support new community-level partners: Based on proven models of community-based engagement, provide targeted training, supportive supervision and mentorship in collaboration with county governments targeting CHWs and CHEWs. Disseminate updated CTBC policies, manuals and guidelines, including ENGAGE-TB guidelines.

b) Pilot new approaches to supporting patients through community structures, such as sustainable livelihood and nutritional support programs.

Improve monitoring and evaluation of community-based TB, leprosy and lung disease interventions to increase accountability to all stakeholders

a) Integrate community-based TB, leprosy and lung disease care indicators in the TIBU and DHIS systems to mirror the reporting of CSO involvement captured in the NTLD Program monitoring system; develop and disseminate related tools to ensure data capture and reporting by NGOs/CSOs and CHEWs.

b) Introduce a register for presumptive TB to allow capturing of screening and referral results, and to enable treatment follow-up.

c) Revise and update peripheral level health facility chalk boards to include comprehensive community TB indicators.d) Identify priority areas for OR jointly with key community stakeholders, including learning institutions. Fully evaluate

pilot projects.

STRATEGIC OBJECTIVES

4.3.

4. C

omm

unit

y En

gage

men

t

71

Contribution to NSP Impacts Outcomes (Community Engagement)

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

• Ensure treatment success of at least 90% among all DS forms of TB

• All newly diagnosed TB patients to be initiated on treatment within 2 days

Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014

• Increase case notification of MDR-TB to at least 75% of estimated prevalence (baseline TBD: DR survey)

• Ensure treatment success of at least 80% among all DR cases

Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014

• Increase treatment success via CHWs to 90%

Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy and other lung diseases, by 2018

• Increased proportion of TB patients accessing social and nutritional support

• Reduction in out-of-pocket expenditures attributed to TB care seeking

Table 10: Impact and Outcome Indicators for Community Engagement

4.3.4. Comm

unity Engagement

72

4.3.

4. C

omm

unit

y En

gage

men

t

Com

mun

ity

Enga

gem

ent

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

sY

ear

1 A

ctiv

itie

sY

r 1

Targ

etY

ear

2 A

ctiv

itie

sY

r 2

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et

Yea

r 3

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ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

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tegi

c A

ppro

ach

1: Id

enti

fy o

ppor

tuni

ties

for

exp

ansi

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f pr

oven

mod

els

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orti

on o

f C

SOs

impl

emen

ting

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GA

GE

TB

acti

viti

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New

C

SOs

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tifi

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and

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ed

to

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t EN

GA

GE

TB

2.

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itiz

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n w

orks

hops

fo

r C

SOs

on

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BC, L

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se a

ctiv

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s

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appi

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SOs

by

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l go

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t in

col

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ith

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2. H

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and

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rly

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m

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and

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all

acto

rs

4.

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ncia

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and

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Prov

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EN

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75%

Prov

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fina

ncia

l su

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t to

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to

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blis

h co

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y m

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100%

Prop

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on o

f lo

st t

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llow

up

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ies,

incl

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g SM

S, f

or c

ase

dete

ctio

n an

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tien

t fo

llow

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n/a

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1.

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sult

ativ

e m

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wit

h po

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ial s

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ce p

rovi

ders

2. P

rocu

rem

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and

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ribu

tion

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pho

nes

3. S

ensi

tiza

tion

mee

ting

s

1.

Con

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ativ

e m

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wit

h po

tent

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ders

2. P

rocu

rem

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and

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pho

nes

3. S

ensi

tiza

tion

mee

ting

s

1.

Con

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e m

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h po

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ce p

rovi

ders

2. P

rocu

rem

ent

and

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ribu

tion

of

pho

nes

3. S

ensi

tiza

tion

mee

ting

s

Num

ber

of T

B pe

ers

enga

ged

for

coun

selin

gSc

ale-

up p

eer-

base

d m

odel

s fo

r cas

e de

tect

ion

and

trea

tmen

t su

ppor

t am

ong

vuln

erab

le a

nd

at-r

isk

popu

lati

ons

n/a

n/a

1. R

ecru

it T

B pe

ers

in 8

cou

ntie

s

2. T

rain

TB

peer

s in

8 c

ount

ies

3. H

old

outr

each

es in

8 c

ount

ies

601.

Rec

ruit

TB

peer

s in

8 c

ount

ies

2. T

rain

TB

peer

s in

8 c

ount

ies

3. H

old

outr

each

es in

8 c

ount

ies

120

1. R

ecru

it T

B pe

ers

in 8

cou

ntie

s

2. T

rain

TB

peer

s in

8 c

ount

ies

3. H

old

outr

each

es in

8 c

ount

ies

120

% i

ncre

ase

in t

he n

umbe

r of

pre

sum

ptiv

e TB

re

ferr

ed f

or s

cree

ning

fro

m t

he C

omm

unit

y "

1. C

SO L

inke

d to

Com

mun

ity

Uni

ts

2.

Dis

sem

inat

ion

mee

ting

s on

EN

GA

GE

TB

oper

atio

nal

guid

elin

es t

o bo

th n

atio

nal

and

coun

ty le

vels

3. H

arm

oniz

atio

n of

TB

Act

ors

wit

hin

Cou

nty

heal

th c

omm

itee

s an

d N

GO

s

Hol

d on

e na

tion

al

stak

ehol

ders

m

eeti

ng1.

H

old

one

nati

onal

an

d 15

C

ount

y m

eeti

ngs

to d

isse

min

ate

CSO

S m

appi

ng a

nd

oper

atio

nal

guid

elin

es o

n EN

GA

GE

TB

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

her

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

”

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

her

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

re

view

m

eeti

ngs

to

upda

te

and

herm

oniz

e ac

tivi

ties

im

plem

ente

d by

al

l ac

tors

Stra

tegi

c A

ppro

ach

2: B

uild

a w

eb o

f co

mm

unit

y or

gani

zati

ons

linke

d to

the

NTL

D P

rogr

am

1. P

ropo

rtio

n of

CSO

s an

d pa

rtne

rs im

plem

enti

ng

com

mun

ity-

base

d TB

, le

pros

y an

d lu

ng h

ealt

h se

rvic

es

2.

Prop

orti

on

of

coun

ties

w

ith

form

al

inte

r-go

vern

men

tal a

gree

men

ts w

ith

NTL

D P

rogr

am

3.

Perc

enta

ge

of

coun

ties

ho

ldin

g qu

arte

rly

com

mun

ity

stak

ehol

ders

m

eeti

ngs

of

thos

e en

gage

d in

TB,

lepr

osy

and

lung

hea

lth

1.

Dis

sem

inat

ion

mee

ting

s on

EN

GA

GE

TB

oper

atio

nal

guid

elin

es t

o bo

th n

atio

nal

and

coun

ty le

vels

2. H

arm

oniz

atio

n of

TB

acto

rs w

ithi

n C

ount

y he

alth

com

mit

ees

and

NG

Os

3. F

orm

aliz

e in

ter-

gove

rnm

enta

l ag

reem

ents

be

twee

n th

e N

TLD

Pr

ogra

m

and

coun

ty

gove

rnm

ents

to

defi

ne r

oles

, re

spon

sibi

litie

s an

d re

sour

ces”

Hol

d qu

arte

rly

C

ount

y st

akeh

olde

rs

revi

ew

mee

ting

s to

up

date

an

d ha

rmon

ize

acti

viti

es

impl

emen

ted

by

all

acto

rs;

esta

blis

h in

ter-

gove

rnm

enta

l ag

reem

ents

20%

1.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e op

erat

iona

l gu

idel

ines

on

EN

GA

GE

TB;

esta

blis

h in

ter-

gove

rnm

enta

l agr

eem

ents

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

har

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

40%

1.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e op

erat

iona

l gu

idel

ines

on

EN

GA

GE

TB;

esta

blis

h in

ter-

gove

rnm

enta

l agr

eem

ents

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

har

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

60%

1.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e op

erat

iona

l gu

idel

ines

on

EN

GA

GE

TB;

esta

blis

h in

ter-

gove

rnm

enta

l agr

eem

ents

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

re

view

m

eeti

ngs

to

upda

te

and

harm

oniz

e ac

tivi

ties

im

plem

ente

d by

al

l ac

tors

80%

Str

ateg

ic A

ppro

ach

3: E

nhan

ce c

apac

ity

at c

omm

unit

y le

vel

Prop

orti

on

of

TB

pati

ent

refe

rral

s fr

om

the

com

mun

ity

1.

Sens

itiz

atio

n of

co

mm

unit

y he

alth

co

mm

itee

s on

TB,

Lep

rosy

and

Lun

g D

isea

se

2.

Prov

ide

ince

ntiv

es

for

CH

Ws

base

d on

as

sign

ed

task

s (p

erfo

rman

ce

base

d)

inte

rven

tion

s

1.

Sens

itiz

atio

n m

eeti

ngs

for

stak

ehol

ders

incl

udin

g C

SOs

6%Se

nsit

izat

ion

mee

ting

s fo

r st

akeh

olde

rs in

clud

ing

CSO

s10

%Se

nsit

izat

ion

mee

ting

s fo

r st

akeh

olde

rs in

clud

ing

CSO

s.12

%Se

nsit

izat

ion

mee

ting

s fo

r st

akeh

olde

rs in

clud

ing

CSO

s.15

%

4.3.4. Comm

unity Engagement

Com

mun

ity

Enga

gem

ent

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

sY

ear

1 A

ctiv

itie

sY

r 1

Targ

etY

ear

2 A

ctiv

itie

sY

r 2

Targ

et

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: Id

enti

fy o

ppor

tuni

ties

for

exp

ansi

on o

f pr

oven

mod

els

Prop

orti

on o

f in

crea

se i

n th

e nu

mbe

r of

CSO

s im

plem

enti

ng E

NG

AG

E TB

act

ivit

ies

1.

N

ew

CSO

s id

enti

fied

an

d fu

nded

to

im

plem

ent

ENG

AG

E TB

2.

Sens

itiz

atio

n w

orks

hops

fo

r C

SOs

on

CBT

BC, L

epro

sy a

nd lu

ng d

isea

se a

ctiv

itie

s

1. M

appi

ng o

f C

SOs

by

Nat

iona

l go

vern

men

t in

col

labo

rati

on w

ith

Cou

nty

gove

rnm

ent

2. H

old

one

nati

onal

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e m

appi

ng

resu

lts

as

wel

l as

oper

atio

nal

guid

elin

es o

n EN

GA

GE

TB

3.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

re

view

m

eeti

ngs

to

upda

te

and

herm

oniz

e ac

tivi

ties

im

plem

ente

d by

all

acto

rs

4.

Prov

ide

Fina

ncia

l su

ppor

t to

C

SOs

to

esta

blis

h co

mm

unit

y m

odel

s on

EN

GA

GE

TB

25%

1. P

rovi

de F

inan

cial

sup

port

to

CSO

s to

es

tabl

ish

com

mun

ity

Mod

els

on E

NG

AG

E TB

2.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e m

appi

ng

resu

lts

as

wel

l as

op

erat

iona

l gui

delin

es

50%

Prov

ide

fina

ncia

l su

ppor

t to

C

SOs

to

esta

blis

h co

mm

unit

y m

odel

s on

EN

GA

GE

TB

75%

Prov

ide

fina

ncia

l su

ppor

t to

C

SOs

to

esta

blis

h co

mm

unit

y m

odel

s on

EN

GA

GE

TB

100%

Prop

orti

on o

f re

duct

ion

in lo

st t

o fo

llow

up

Ro

ll-ou

t us

e of

mob

ile t

echn

olog

ies,

incl

udin

g SM

S, f

or c

ase

dete

ctio

n an

d pa

tien

t fo

llow

-up

n/a

n/a

1.

Con

sult

ativ

e m

eeti

ngs

wit

h po

tent

ial s

ervi

ce p

rovi

ders

2. P

rocu

rem

ent

and

dist

ribu

tion

of

pho

nes

3. S

ensi

tiza

tion

mee

ting

s

1.

Con

sult

ativ

e m

eeti

ngs

wit

h po

tent

ial s

ervi

ce p

rovi

ders

2. P

rocu

rem

ent

and

dist

ribu

tion

of

pho

nes

3. S

ensi

tiza

tion

mee

ting

s

1.

Con

sult

ativ

e m

eeti

ngs

wit

h po

tent

ial s

ervi

ce p

rovi

ders

2. P

rocu

rem

ent

and

dist

ribu

tion

of

pho

nes

3. S

ensi

tiza

tion

mee

ting

s

Num

ber

of T

B pe

ers

enga

ged

for

coun

selin

gSc

ale-

up p

eer-

base

d m

odel

s fo

r cas

e de

tect

ion

and

trea

tmen

t su

ppor

t am

ong

vuln

erab

le a

nd

at-r

isk

popu

lati

ons

n/a

n/a

1. R

ecru

it T

B pe

ers

in 8

cou

ntie

s

2. T

rain

TB

peer

s in

8 c

ount

ies

3. H

old

outr

each

es in

8 c

ount

ies

601.

Rec

ruit

TB

peer

s in

8 c

ount

ies

2. T

rain

TB

peer

s in

8 c

ount

ies

3. H

old

outr

each

es in

8 c

ount

ies

120

1. R

ecru

it T

B pe

ers

in 8

cou

ntie

s

2. T

rain

TB

peer

s in

8 c

ount

ies

3. H

old

outr

each

es in

8 c

ount

ies

120

% i

ncre

ase

in t

he n

umbe

r of

pre

sum

ptiv

e TB

re

ferr

ed f

or s

cree

ning

fro

m t

he C

omm

unit

y "

1. C

SO L

inke

d to

Com

mun

ity

Uni

ts

2.

Dis

sem

inat

ion

mee

ting

s on

EN

GA

GE

TB

oper

atio

nal

guid

elin

es t

o bo

th n

atio

nal

and

coun

ty le

vels

3. H

arm

oniz

atio

n of

TB

Act

ors

wit

hin

Cou

nty

heal

th c

omm

itee

s an

d N

GO

s

Hol

d on

e na

tion

al

stak

ehol

ders

m

eeti

ng1.

H

old

one

nati

onal

an

d 15

C

ount

y m

eeti

ngs

to d

isse

min

ate

CSO

S m

appi

ng a

nd

oper

atio

nal

guid

elin

es o

n EN

GA

GE

TB

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

her

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

”

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

her

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

re

view

m

eeti

ngs

to

upda

te

and

herm

oniz

e ac

tivi

ties

im

plem

ente

d by

al

l ac

tors

Stra

tegi

c A

ppro

ach

2: B

uild

a w

eb o

f co

mm

unit

y or

gani

zati

ons

linke

d to

the

NTL

D P

rogr

am

1. P

ropo

rtio

n of

incr

ease

in t

he n

umbe

r of

CSO

s an

d pa

rtne

rs

impl

emen

ting

co

mm

unit

y-ba

sed

TB, l

epro

sy a

nd lu

ng h

ealt

h se

rvic

es

2.

Prop

orti

on

of

coun

ties

w

ith

form

al

inte

r-go

vern

men

tal a

gree

men

ts w

ith

NTL

D P

rogr

am

3.

Perc

enta

ge

of

coun

ties

ho

ldin

g qu

arte

rly

com

mun

ity

stak

ehol

ders

m

eeti

ngs

of

thos

e en

gage

d in

TB,

lepr

osy

and

lung

hea

lth

1.

Dis

sem

inat

ion

mee

ting

s on

EN

GA

GE

TB

oper

atio

nal

guid

elin

es t

o bo

th n

atio

nal

and

coun

ty le

vels

2. H

erm

oniz

atio

n of

TB

acto

rs w

ithi

n C

ount

y he

alth

com

mit

ees

and

NG

Os

3. F

orm

aliz

e in

ter-

gove

rnm

enta

l ag

reem

ents

be

twee

n th

e N

TLD

Pr

ogra

m

and

coun

ty

gove

rnm

ents

to

defi

ne r

oles

, re

spon

sibi

litie

s an

d re

sour

ces”

Hol

d qu

arte

rly

C

ount

y st

akeh

olde

rs

revi

ew

mee

ting

s to

up

date

an

d he

rmon

ize

acti

viti

es

impl

emen

ted

by

all

acto

rs;

esta

blis

h in

ter-

gove

rnm

enta

l ag

reem

ents

20%

1.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e op

erat

iona

l gu

idel

ines

on

EN

GA

GE

TB;

esta

blis

h in

ter-

gove

rnm

enta

l agr

eem

ents

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

her

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

40%

1.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e op

erat

iona

l gu

idel

ines

on

EN

GA

GE

TB;

esta

blis

h in

ter-

gove

rnm

enta

l agr

eem

ents

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

rev

iew

mee

ting

s to

up

date

and

her

mon

ize

acti

viti

es

impl

emen

ted

by a

ll ac

tors

”

60%

1.

Hol

d on

e na

tion

al

and

15

Cou

nty

mee

ting

s to

dis

sem

inat

e op

erat

iona

l gu

idel

ines

on

EN

GA

GE

TB;

esta

blis

h in

ter-

gove

rnm

enta

l agr

eem

ents

2.

Hol

d qu

arte

rly

Cou

nty

stak

ehol

ders

re

view

m

eeti

ngs

to

upda

te

and

herm

oniz

e ac

tivi

ties

im

plem

ente

d by

al

l ac

tors

80%

Str

ateg

ic A

ppro

ach

3: E

nhan

ce c

apac

ity

at c

omm

unit

y le

vel

Prop

orti

on

of

TB

pati

ent

refe

rral

s fr

om

the

com

mun

ity

1.

Sens

itiz

atio

n of

co

mm

unit

y he

alth

co

mm

itee

s on

TB,

Lep

rosy

and

Lun

g D

isea

se

2.

Prov

ide

ince

ntiv

es

for

CH

Ws

base

d on

as

sign

ed

task

s (p

erfo

rman

ce

base

d)

inte

rven

tion

s

1.

Sens

itiz

atio

n m

eeti

ngs

stak

ehol

ders

incl

udin

g C

SOs.

6%Se

nsit

izat

ion

mee

ting

s st

akeh

olde

rs in

clud

ing

CSO

s.10

%Se

nsit

izat

ion

mee

ting

s st

akeh

olde

rs in

clud

ing

CSO

s.12

%Se

nsit

izat

ion

mee

ting

s st

akeh

olde

rs in

clud

ing

CSO

s.15

%

Com

mun

ity

Enga

gem

ent

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

Inte

rven

tion

sY

ear

1 A

ctiv

itie

sY

r 1

Targ

etY

ear

2 A

ctiv

itie

sY

r 2

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et

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r 3

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ivit

ies

Yr

3 Ta

rget

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r 4

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ivit

ies

Yr

4 Ta

rget

Prop

orti

on

of

TB

pati

ent

refe

rral

s fr

om

the

com

mun

ity

1. S

uppo

rt C

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ith

allo

wan

ces

whe

n un

dert

akin

g as

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ed t

asks

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uppo

rt C

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tran

spor

t al

low

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to

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uct

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sion

s on

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pros

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lu

ng

dise

as

acti

viti

es o

nce

a w

eek

per

CU

3. S

uppo

rt m

onth

ly d

ialo

gue

day

s in

all

func

tion

al C

Us

1.

Supp

ort

CH

Ws

wit

h al

low

ance

w

hen

unde

rtak

ing

assi

gned

tas

ks

2.

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ppor

t M

onth

ly

dial

ogue

da

ys in

all

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tion

al C

Us

1.

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ort

C

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ith

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wan

ce

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n un

dert

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ed t

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ppor

t M

onth

ly

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ogue

da

ys in

all

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tion

al C

Us

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ort

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s w

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wan

ces

whe

n un

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akin

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sign

ed t

asks

2.

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ort

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thly

di

alog

ue

days

in a

ll Fu

ncti

onal

CU

s

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ber

of H

CW

s tr

aine

d 1.

Cap

acit

y bu

ildin

g fo

r co

mm

unit

y TB

act

ors

(CH

EWs,

CH

Ws,

CSO

s) o

n TB

, lep

rosy

and

lung

di

seas

es.

This

will

inv

olve

tra

inin

g in

clud

ing

on-j

ob-t

rain

ing

and

supp

ort

supe

rvis

ion

2.

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tors

hip

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ogra

m,

thro

ugh

wel

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min

g ce

ntre

s of

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celle

nce

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er

coun

ties

) on

com

mun

ity-

base

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and

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osy

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viti

es

n/a

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ning

of

H

CW

s fr

om

10

coun

ties

on

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are

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ning

of

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CW

s fr

om

10

coun

ties

on

TB c

are

500

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ning

of

H

CW

s fr

om

10

coun

ties

on

TB c

are

500

n/a

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ning

of

C

HEW

s fr

om

10

coun

ties

on

TB c

are

500

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ning

of

C

HEW

s fr

om

10

coun

ties

on

TB c

are

500

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ning

of

C

HEW

s fr

om

10

coun

ties

on

TB c

are

500

n/a

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ning

of

C

HW

s fr

om

10

coun

ties

on

TB c

are

1,

750

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of

C

HW

s fr

om

10

coun

ties

on

TB c

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750

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of

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HW

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om

10

coun

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are

1,

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ber

of p

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grou

ps t

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oord

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ed

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p by

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tivi

ties

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logu

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itiz

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izat

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w

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itiz

e sc

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e co

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ize

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4.3.

4. C

omm

unit

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gage

men

t

4.3.4. Comm

unity Engagement

Com

mun

ity

Enga

gem

ent

Ope

rati

onal

Pla

n

Out

put

Indi

cato

r(s)

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rven

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sY

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ctiv

itie

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r 1

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etY

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r 2

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et

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r 3

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ivit

ies

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3 Ta

rget

Yea

r 4

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ivit

ies

Yr

4 Ta

rget

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tegi

c A

ppro

ach

5: C

reat

e pa

tien

t en

gage

men

t gu

idel

ines

and

upd

ate

othe

r po

licie

s an

d to

ols

Num

ber

of p

olic

ies,

man

uals

, gui

delin

e re

vise

d,

prin

ted

and

diss

emin

ated

1. D

evel

op p

atie

nt e

ngag

emen

t gu

idel

ines

for

C

HW

s an

d C

HEW

s

2. U

pdat

e ex

isti

ng p

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ies,

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delin

es a

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late

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ity-

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es1

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se c

omm

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pol

icie

s,

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anua

ls a

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2

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tegi

c A

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6: H

arm

oniz

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t le

vels

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Har

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ized

pa

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fo

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re f

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Hol

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unty

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ssem

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odel

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lem

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el

188

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d an

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188

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ct a

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atio

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w

ith

stak

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ders

4.3.5. Enhance multi-sectoral response to TB/HIV1. Situational Analysis

Kenya has a heavy dual burden of TB and HIV. HIV remains a key driver of the TB epidemic, with six in one hundred (5.6%) Kenyans aged 15-64 years being HIV infected. Some counties have reported up to four times the national HIV prevalence (See Map 9).

In 2013, over one-third (37%) of notified TB patients nationally were HIV infected, compared to 13% globally. Some regions reported up to 75% HIV infection among TB patients.

Despite the disease burden, Kenya has been recognized as a leader in implementing the recommended WHO TB/HIV collaborative activities. In 2013, 19 out of every 20 patients with TB disease (95%) had a documented HIV test result with 83% of those HIV-infected being put on cART and almost all on CPT. Intensified TB case finding has been strengthened. Data collected during the 2014 mid-term review revealed that 83% of PLHIV in care and treatment were screened for TB during their clinical visit. It was however noted that only 2% of those screening negative for TB were initiated on isoniazid preventive therapy (IPT). Guidelines for TB infection prevention and control (IPC) in health care and congregate settings were developed and disseminated in 2009. However, full operationalization at facility and community level is yet to be realized.

4.3.

5. M

ulti

-sec

tora

l Res

pons

e to

TB/

HIV

Map 9: Prevalence of HIV and Number of TB/HIV Cases Reported by County

Figure 20: TB/HIV and Overall Notification Rates by County, 2013

77

National TB surveillance data indicates that HIV-infected TB patients are three times more likely to die compared to those who are HIV negative. Similarly TB patients who decline an HIV test are two times more likely to die or get lost to follow-up compared to HIV negative TB patients. While there is near-universal HIV Testing and Counseling (HTC) coverage for TB patients, there is need to characterize populations not being tested for HIV to close the gaps in HTC. Sexual partner and family HIV testing needs to be enhanced by leveraging on the gains made by the HIV program.

This strategic plan focuses on closing gaps using innovative approaches in PITC, infection prevention and control, early initiation of cART, intensified TB case finding, as well as addressing TB/HIV program quality issues and institutionalizing TB/HIV collaborative activities.

2. Strategic Direction(s) for 2015-2018

Though gains have been made in Kenya in the implementation of TB/HIV collaborative activities, particularly of the 5Is, key elements to support sustainable TB/HIV practices are weak or lacking. The following TB/HIV strategic directions will be geared towards addressing these weaknesses to ensure sustainability in implementing all the TB/HIV collaborative activities, while drawing on innovations to scale up any successes achieved, such as those made during piloting of IPT in some regions. In addition, there will be need to leverage on devolution to support any gains made so far. Strategic interventions must include formation of TB/HIV coordinating bodies, scaling up IPT, and strengthening infection prevention and control at health care and congregate settings.

3. Proposed Approaches

a) Formation of TB/HIV coordinating bodies

TB/HIV coordinating bodies will support TB/HIV collaborative activities with clear terms of reference outlining the scope of work at each level of service provision, as developed by the national TB/HIV coordinating body. The coordinating body at national level will be charged with the revision and dissemination of the new TB/HIV guidelines using an integrated approach towards guideline development and dissemination. Guideline dissemination will involve the use of faster, low cost electronic/digital methods.

The national and county level coordinating bodies will seek sufficient human resources for health to support the expanded TB/HIV collaborative activities from national and county governments. This will include hiring or task shifting of health care workers, both at the national and county levels, to enable the planned scale up of TB/HIV collaborative activities. Increasing the capacity of existing health care workers to provide quality services is also a priority, and training will reflect the geographic focus (see box). Due to high staff turnover and the inherent need for refresher training, continuous capacity building is critical, and innovative sustainable approaches for conducting in-service staff training will include having structured and updated continuous medical education programs held at regular intervals (web-based learning modules, web-based CPD accredited self-taught modules). To capitalize on the successful models employed by some facilities, the evolution of these facilities as TB/HIV centres of excellence is envisioned to create hubs for more decentralized capacity building and mentorship.

The national coordinating body will also develop a TB/HIV Continuous Quality Improvement (CQI) framework as part of the larger TB CQI framework to give guidance on quality review of the TB/HIV program. The TB/HIV coordinating body at county level will be charged with coordinating TB/HIV CQI reviews at sub-county, facility and community levels. TB/HIV coordinating bodies and stakeholders at all levels will conduct regular TB/HIV performance reviews and agree on corrective

Figure 21: HIV Testing and Co-infection Rates among Notified TB Patients, 2008-2012

4.3.5. Multi-sectoral Response to TB/H

IV

78

Figure 22: ART and CPT Uptake

measure to address unmet targets.

b) TB/HIV monitoring and evaluation system

The establishment of monitoring and evaluation systems that comprehensively address all TB/HIV collaborative activities will be achieved through the development of a comprehensive TB/HIV M&E framework, integrated into the NTLD Program and NASCOP M&E framework.

This comprehensive TB/HIV M&E framework will guide the tracking of TB/HIV performance indicators by counties, uniformed forces, and key populations. Additionally, TB/HIV standardized program indicators will also be integrated into the national health management information system (HMIS).

Counties and sub-counties will have their capacities to analyze TB/HIV data enhanced. This will boost the utilization of data in decision making and for programme improvement.

c) IPT for all eligible PLHIV

IPT has been implemented successfully in a few select facilities in Kenya. The rapid scale-up of this strategic intervention to reduce development of TB disease among PLHIV will be pegged on collaborative efforts with NASCOP and NACC. In particular, strategies will be implemented to improve isoniazid commodity security, strengthen IPT M&E systems and scale up contact investigation.

d) Scale up of TB IPC in health care and congregate settings

The implementation of TB infection prevention and control measures within health facilities and congregate settings has been largely unsuccessful, despite the development of the national TB infection control guidelines in 2009. This strategic plan lays emphasis on preventing TB transmission within the health facilities and the community. It is a key component of the prevention strategy.

The scale up and institutionalization of TB IPC activities at facility and community levels will be achieved through revision and dissemination of new TB IPC guidelines to include development and implementation of TB and TB/HIV work place policies, continuous capacity building of TB managers, health facility managers, and HCWs using trained TB IC TOTs and mentors from an established web-based training database. In addition, resource mobilization for health facility infrastructural improvement at national and county levels will be required to ensure that infrastructural development is carried out in line with TB IC measures through leveraging on other ministries, such as the Ministry of Housing to change planning policies. Additionally, there is need to develop TB IPC CQI and M&E systems.

e) Integration of TB and HIV servicesDuring the 2014 mid-term review, 79% of the evaluated facilities reported integrated TB and HIV services, providing an

1  |  P a g e    

 

   

Sustain  the  gains,  in  the  context  of  a  newly  devolved  system  

• Sustaining  na;onwide  coverage  of  HIV  tes;ng  among  TB  pa;ents  and  cART  among  TB/HIV  co-­‐infected    

Intensify  efforts  to  find  “missing”  cases  

• Scale-­‐up  IPT,  IPC  and  TB/HIV  service  delivery  integra;on  in  coun;es  with  HIV  prevalence  of  >5%  in  Year  1,  and  in  coun;es  with  HIV  prevalence  of  2.5-­‐5%  in  subsequent  years  

• Enhance  M&E  of  TB/HIV  collabora;ve  ac;vi;es  to  beWer  idenXy  gaps  in  programme  performance  

Reduce  transmission  

• Intensify  infec;on  control  in  high  HIV  prevalence  contexts  

Prevent  ac;ve  disease  and  morbidity  

• Scale  up  CPT  and  cARTfor  all  TB/HIV  co-­‐infected  pa;ents  

STRATEGIC OBJECTIVES

4.3.

5. M

ulti

-sec

tora

l Res

pons

e to

TB/

HIV

79

opportunity for Kenya to scale-up IPT, implement improved TB infection control practices, and refine other elements of the TB/HIV collaborative activities. There is need to leverage on the on-going scale up of eMTCT through option B plus (ART for all pregnant women living with HIV) to integrate TB services within all HIV providing facilities.

f) TB intensified case finding

Screening for TB among PLHIV is routinely offered to identify those with presumptive TB. Scaling up this strategic intervention to improve coverage of TB ICF will be done through leveraging on the national PITC strategy to conduct TB ICF in all HTC settings, addressing quality issues in screening and scaling up new diagnostic technologies, including making the Xpert MTB Rif test the first test for all PLHIV with presumptive TB.

Coverage of TB intensified case finding will be increased by leveraging on the PITC strategy to conduct TB ICF in all HTC settings, as well as the aforementioned eMTCT strategy to introduce TB ICF to key populations and in high risk settings. In addition, TB diagnostics will be supported by procuring more CXR machines, capacity building on X-ray interpretation and zero costing CXRs to improve access to quality radiography. In addition, there will be need to conduct remote (web-based) clinical and radiological consultations. CQI processes will be established to monitor the quality of TB ICF.

g) Immediate cART and CPT uptake

4.3.5. Multi-sectoral Response to TB/H

IV

Geographic Focus

Sustaining gains nationwide: The current efforts and gains already made in HIV testing and CPT uptake will be sustained in all the counties. Activities related to TB-HIV coordination, monitoring and evaluation for TB HIV activities, TB intensified case finding among PLHIV, immediate ART for TB HIV co-infected and IPT for children less than 5 years old exposed to smear positive index cases will be accelerated across all the 47 counties in Kenya.

Intensified action in most at-risk populations: focus on the scale-up of isoniazid prophylaxis, integration of TB/HIV service delivery and TB infection prevention and control in health facilities

>5% HIV prevalence: Year 1 focus in 21 counties with HIV prevalence in the general population above 5% (see chart)

2.5-5% HIV prevalence: Year 2-4 scale-up in 19 counties with HIV prevalence in the general population between 2.5-5%

<2.5% HIV prevalence: Sustained IPT, IPC and service delivery integration in 7 counties with HIV prevalence in the general population below 2.5%

Box 6Major achievements have been made in the provision of cART for TB/HIV co-infected patients. This strategic plan will address opportunities for further scale-up, ensuring that at least 95% of TB/HIV co-infected patients are initiated on ART and that the initiation of cART is done early in the course of TB treatment, i.e, within two months.

The scale-up of immediate cART and CPT will be achieved by ensuring the dissemination of revised national TB/HIV policies and clinical guidelines to all care providers, using innovative approaches to implement evidence based practices, integration of TB and HIV service delivery, leveraging on the decentralization of cART through the national eMTCT strategy, availing TB/HIV patient friendly treatment regimens, institutionalization of TB/HIV CQI activities, conducting routine monitoring, evaluation of early cART uptake and monitoring of TB/HIV treatment outcomes. It is necessary to use gains in HIV testing among TB patients to screen family members for TB/HIV, to reduce the burden of HIV.

h) Conduct operations research on 5I’s implementation

There is need to evaluate performance of the ICF/IPT screening tool to assess reasons why only 7% of all PLHIV screened positive. Measurement of the timing of cART initiation among co-infected TB patients will assess timeliness regarding the quality of care offered to co-infected TB patients. Additionally, there is need to evaluate implemented innovative approaches to improving access to TB diagnostics, such as the use of GeneXpert as an initial test for PLHIV, as well as incentives provided for diagnostic evaluation.

80

Contribution to NSP Impacts Outcomes (TB/HIV)

Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014

• Increase to 100% the proportion of counties with functional TB/HIV coordinating bodies

• Increase to 95% the proportion of PLHIV in care screened for TB at their last clinical visit using the ICF screening tool in HIV clinics

• Sustain universal CPT coverage among HIV+ TB patients• Increase to 90% the proportion of HIV+ TB patients accessing

cART• Increase to 90%, the proportion of health facilities

implementing the minimum TB IPC package• Increase to 80% the proportion of eligible persons for IPT who

receive INH

Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014.

• Increase to 75% the proportion of facilities implementing CQI in TB/HIV

Table 11: Impact and Outcome Indicators for Multi-sectoral Response to TB/HIV

4.3.

5. M

ulti

-sec

tora

l Res

pons

e to

TB/

HIV

81

TB/H

IV O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: F

orm

atio

n of

TB/

HIV

coo

rdin

atin

g bo

dies

Prop

orti

on o

f co

unti

es a

nd s

ub-c

ount

ies

wit

h ac

tive

TB/

HIV

coo

rdin

atin

g bo

dies

Hol

d na

tion

al,

coun

ty a

nd s

ubco

unty

TB/

HIV

coo

rdin

atin

g bo

dies

mee

ting

s4

mee

ting

s at

nat

iona

l,cou

nty

and

sub-

coun

ty25

4 m

eeti

ngs

at n

atio

nal,

coun

ty

and

sub-

coun

ty10

04

mee

ting

s at

nat

iona

l, co

unty

and

su

b-co

unty

100

4 m

eeti

ngs

at n

atio

nal,

coun

ty

and

sub-

coun

ty10

0

Con

duct

na

tion

al

TB/H

IV

stak

ehol

ders

' m

eeti

ng2

mee

ting

s2

mee

ting

s2

mee

ting

s1

mee

ting

Dev

elop

ToR

s ou

tlin

ing

the

scop

e of

wor

k of

nat

iona

l an

d co

unty

TB/

HIV

cor

dina

ting

bo

dies

1 m

eeti

ngn/

an/

an/

a

Hol

d co

unty

TB/

HIV

pla

nnin

g m

eeti

ngs

1 m

eeti

ng/c

ount

yn/

an/

an/

a

Hol

d qu

arte

ly

TB/H

IV

TWG

m

eeti

ngs

at

nati

onal

leve

l 4

mee

ting

s4

mee

ting

s4

mee

ting

s4

mee

ting

s

Num

ber

of

acti

ve

nati

onal

TB

/HIV

co

ordi

nati

ng b

odie

sH

old

bi

annu

al

nati

onal

le

vel

TB/

HIV

im

plem

enti

ng

part

ners

' m

eeti

ng

high

light

ing

prov

isio

nal s

uppo

rt b

y pa

rtne

rs

2 m

eeti

ngs

12

mee

ting

s1

2 m

eeti

ngs

12

mee

ting

s1

Stra

tegi

c A

ppro

ach

2: S

tren

gthe

n TB

/HIV

mon

itor

ing

and

eval

uati

on s

yste

m

Prop

orti

on o

f fa

cilit

ies

repo

rtin

g on

all

TB/H

IV

indi

cato

rs

mon

thly

th

roug

h th

e na

tion

al r

epor

ting

sys

tem

(DH

IS)

Nat

iona

l le

vel

wor

shop

to

deve

lop

TB/H

IV

prog

ram

in

dica

tors

fo

r in

tegr

atio

n in

to

nati

onal

HM

IS (I

PT ,

ICF,

con

tact

trac

ing,

IPC

) an

d TB

/HIV

CQ

Is f

ram

ewor

k.

1 w

orks

hop

800

>90

0>

900

>90

Cou

nty

sens

itiz

atio

ns

on

TB

H

IV

data

an

alys

is a

nd u

tiliz

atio

n of

dat

a fo

r de

cisi

on

mak

ing

incl

udin

g im

prov

ing

the

TB-H

IV

qual

ity

of c

are.

1 se

nsit

izat

ion/

coun

ty1

11

Sub-

Cou

nty

sens

itiz

atio

ns o

n T

B H

IV d

ata

anal

ysis

and

uti

lizat

ion

of d

ata

for

deci

sion

m

akin

g in

clud

ing

impr

ovin

g th

e TB

-HIV

qu

alit

y of

car

e.

47 s

ensi

tiza

tion

/cou

nty

00

0

Qua

rter

ly

coun

ty

TB/H

IV

perf

orm

ance

re

view

mee

ting

s4

coun

ty d

ata

revi

ew m

eeti

ngs

for

the

40 m

id a

nd h

igh

burd

en

HIV

pre

vale

nce

coun

ties

100

4 co

unty

dat

a re

view

mee

ting

s fo

r th

e 40

mid

and

hig

h bu

rden

H

IV p

reva

lenc

e co

unti

es

100

4 co

unty

dat

a re

view

mee

ting

s fo

r th

e 40

mid

and

hig

h bu

rden

HIV

pr

eval

ence

cou

ntie

s

100

4 co

unty

dat

a re

view

mee

ting

s fo

r th

e 40

mid

and

hig

h bu

rden

HIV

pr

eval

ence

cou

ntie

s

100

Prop

orti

on o

f pl

anne

d bi

ann

ual

supp

ort

supe

rvis

ion

of h

igh

burd

en c

ount

ries

don

e by

TB/

HIV

nat

iona

l coo

rdin

atin

g bo

dy

Con

duct

bi

annu

al n

atio

nal

leve

l te

chni

cal

assi

stan

ce o

f th

e 21

hi

gh b

urde

n co

unti

es

on im

plem

enta

tion

of

TB/H

IV a

ctiv

itie

s

21 c

ount

ies

(cou

ntie

s w

ith

HIV

pr

eval

ence

>5

%)

21 c

ount

ies

(cou

ntie

s w

ith

HIV

pr

eval

ence

>5

%)

21

coun

ties

(c

ount

ies

wit

h H

IV

prev

alen

ce >

5 %

)21

co

unti

es

(cou

ntie

s w

ith

HIV

pr

eval

ence

>5

%)

Stra

tegi

c A

ppro

ach

3: IP

T fo

r al

l elig

ible

PLH

IV a

nd c

hild

ren

unde

r 5

expo

sed

to T

B co

ntac

ts

Prop

orti

on

of

plan

ned

wor

ksho

ps

for

deve

lopm

ent o

f IPT

tool

s an

d se

nsit

izat

ion

pack

age

cond

ucte

d

Dev

elop

men

t of

co

mpr

ehen

sive

IP

T se

nsit

izat

ion

pack

age

at

TWG

leve

l1

mee

ting

2n/

a0

n/a

0n/

a0

Con

duct

a w

orks

hop

to d

evel

op a

n IP

T M

&E

fram

ewor

k in

clud

ing

IPT

data

re

port

ing

at c

ount

y an

d na

tion

al l

evel

s, a

s w

ell

as

stan

dard

izat

ion

of

all

ICF/

IPT

card

s,

IPT

regi

ster

, IPT

app

oint

men

t ca

rds

and

cont

act

trac

ing

regi

ster

s

1 m

eeti

ngn/

an/

an/

a

Prop

orti

on o

f el

igib

le P

LHIV

and

chi

ldre

n un

der

5 w

ho

are

cont

acts

of

sm

ear-

posi

tive

TB

pati

ents

put

on

IPT

Nat

iona

l ro

ll ou

t of

IPT

im

plem

enta

tion

to

incl

ude

impl

emen

ting

par

tner

s, M

oH (N

LTD

-Pr

ogra

m

&

NA

SCO

P),

as

wel

l as

co

unty

he

ads

1 m

eeti

ng25

%n/

a50

%n/

a80

%n/

a>

80% 4.3.5. M

ulti-sectoral Response to TB/HIV

TB/H

IV O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: F

orm

atio

n of

TB/

HIV

coo

rdin

atin

g bo

dies

Prop

orti

on o

f co

unti

es a

nd s

ub-c

ount

ies

wit

h ac

tive

TB/

HIV

coo

rdin

atin

g bo

dies

Hol

d na

tion

al,

coun

ty a

nd s

ubco

unty

TB/

HIV

coo

rdin

atin

g bo

dies

mee

ting

s4

mee

ting

s at

nat

iona

l,cou

nty

and

sub-

coun

ty25

4 m

eeti

ngs

at n

atio

nal,

coun

ty

and

sub-

coun

ty10

04

mee

ting

s at

nat

iona

l, co

unty

and

su

b-co

unty

100

4 m

eeti

ngs

at n

atio

nal,

coun

ty

and

sub-

coun

ty10

0

Con

duct

na

tion

al

TB/H

IV

stak

ehol

ders

' m

eeti

ng2

mee

ting

s2

mee

ting

s2

mee

ting

s1

mee

ting

Dev

elop

ToR

s ou

tlin

ing

the

scop

e of

wor

k of

nat

iona

l an

d co

unty

TB/

HIV

cor

dina

ting

bo

dies

1 m

eeti

ngn/

an/

an/

a

Hol

d co

unty

TB/

HIV

pla

nnin

g m

eeti

ngs

1 m

eeti

ng/c

ount

yn/

an/

an/

a

Hol

d qu

arte

ly

TB/H

IV

TWG

m

eeti

ngs

at

nati

onal

leve

l 4

mee

ting

s4

mee

ting

s4

mee

ting

s4

mee

ting

s

Num

ber

of

acti

ve

nati

onal

TB

/HIV

co

ordi

nati

ng b

odie

sH

old

bi

annu

al

nati

onal

le

vel

TB/

HIV

im

plem

enti

ng

part

ners

' m

eeti

ng

high

light

ing

prov

isio

nal s

uppo

rt b

y pa

rtne

rs

2 m

eeti

ngs

12

mee

ting

s1

2 m

eeti

ngs

12

mee

ting

s1

Stra

tegi

c A

ppro

ach

2: S

tren

gthe

n TB

/HIV

mon

itor

ing

and

eval

uati

on s

yste

m

Prop

orti

on o

f fa

cilit

ies

repo

rtin

g on

all

TB/H

IV

indi

cato

rs

mon

thly

th

roug

h th

e na

tion

al r

epor

ting

sys

tem

(DH

IS)

Nat

iona

l le

vel

wor

shop

to

deve

lop

TB/H

IV

prog

ram

in

dica

tors

fo

r in

tegr

atio

n in

to

nati

onal

HM

IS (I

PT ,

ICF,

con

tact

trac

ing,

IPC

) an

d TB

/HIV

CQ

Is f

ram

ewor

k.

1 w

orks

hop

800

>90

0>

900

>90

Cou

nty

sens

itiz

atio

ns

on

TB

H

IV

data

an

alys

is a

nd u

tiliz

atio

n of

dat

a fo

r de

cisi

on

mak

ing

incl

udin

g im

prov

ing

the

TB-H

IV

qual

ity

of c

are.

1 se

nsit

izat

ion/

coun

ty1

11

Sub-

Cou

nty

sens

itiz

atio

ns o

n T

B H

IV d

ata

anal

ysis

and

uti

lizat

ion

of d

ata

for

deci

sion

m

akin

g in

clud

ing

impr

ovin

g th

e TB

-HIV

qu

alit

y of

car

e.

47 s

ensi

tiza

tion

/cou

nty

00

0

Prop

orti

on o

f pl

anne

d bi

ann

ual

supp

ort

supe

rvis

ion

of h

igh

burd

en c

ount

ries

don

e by

TB/

HIV

nat

iona

l coo

rdin

atin

g bo

dy

Qua

rter

ly

coun

ty

TB/H

IV

perf

orm

ance

re

view

mee

ting

s4

coun

ty d

ata

revi

ew m

eeti

ngs

for

the

40 m

id a

nd h

igh

burd

en

HIV

pre

vale

nce

coun

ties

100

4 co

unty

dat

a re

view

mee

ting

s fo

r th

e 40

mid

and

hig

h bu

rden

H

IV p

reva

lenc

e co

unti

es

100

4 co

unty

dat

a re

view

mee

ting

s fo

r th

e 40

mid

and

hig

h bu

rden

HIV

pr

eval

ence

cou

ntie

s

100

4 co

unty

dat

a re

view

mee

ting

s fo

r th

e 40

mid

and

hig

h bu

rden

HIV

pr

eval

ence

cou

ntie

s

100

Con

duct

bi

annu

al n

atio

nal

leve

l te

chni

cal

assi

stan

ce o

f th

e 21

hi

gh b

urde

n co

unti

es

on im

plem

enta

tion

of

TB/H

IV a

ctiv

itie

s

21 c

ount

ies

(cou

ntie

s w

ith

HIV

pr

eval

ence

>5

%)

21 c

ount

ies

(cou

ntie

s w

ith

HIV

pr

eval

ence

>5

%)

21

coun

ties

(c

ount

ies

wit

h H

IV

prev

alen

ce >

5 %

)21

co

unti

es

(cou

ntie

s w

ith

HIV

pr

eval

ence

>5

%)

Stra

tegi

c A

ppro

ach

3: IP

T fo

r al

l elig

ible

PLH

IV a

nd c

hild

ren

unde

r 5

expo

sed

to T

B co

ntac

ts

Prop

orti

on

of

plan

ned

wor

ksho

ps

for

deve

lopm

ent o

f IPT

tool

s an

d se

nsit

izat

ion

pack

age

cond

ucte

d

Dev

elop

men

t of

co

mpr

ehen

sive

IP

T se

nsit

izat

ion

pack

age

at

TWG

leve

l1

mee

ting

2n/

a0

n/a

0n/

a0

Con

duct

a w

orks

hop

to d

evel

op a

n IP

T M

&E

fram

ewor

k in

clud

ing

IPT

data

re

port

ing

at c

ount

y an

d na

tion

al l

evel

s, a

s w

ell

as

stan

dard

izat

ion

of

all

ICF/

IPT

card

s,

IPT

regi

ster

, IPT

app

oint

men

t ca

rds

and

cont

act

trac

ing

regi

ster

s

1 m

eeti

ngn/

an/

an/

a

Prop

orti

on o

f el

igib

le P

LHIV

and

chi

ldre

n un

der

5 w

ho

are

cont

acts

of

sm

ear-

posi

tive

TB

pati

ents

put

on

IPT

Nat

iona

l ro

ll ou

t of

IPT

im

plem

enta

tion

to

incl

ude

impl

emen

ting

par

tner

s, M

oH (N

LTD

-Pr

ogra

m

&

NA

SCO

P),

as

wel

l as

co

unty

he

ads

1 m

eeti

ng25

%n/

a50

%n/

a80

%n/

a>

80%

4.3.

5. M

ulti

-sec

tora

l Res

pons

e to

TB/

HIV

4.3.5. Multi-sectoral Response to TB/H

IV

TB/H

IV O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Con

duct

co

unty

le

vel

IPT

sens

itiz

atio

ns

thro

ugh

impl

emen

ting

par

tner

s IP

T co

unty

lev

el s

ensi

tiza

tion

s fo

r 21

high

H

IV

bu

rden

co

unti

es

IPT

coun

ty

leve

l se

nsit

izat

ions

fo

r 19

cou

ntie

sn/

an/

a

Con

duct

fa

cilit

y le

vel

men

tors

hip

and

trai

ning

thr

ough

CH

MT

and

Impl

emen

ting

pa

rtne

rs

Faci

lity

leve

l tr

aini

ng

and

men

tors

hio

fo

r IP

T im

plem

enti

ng

site

s in

hi

gh

burd

ened

cou

ntie

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hio

for I

PT im

plem

enti

ng

site

s in

all

hig

h an

d m

ediu

m

burd

ened

cou

ntie

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hio

for

IPT

im

plem

enti

ng

site

s in

al

l

high

an

d m

ediu

m

burd

ened

cou

ntie

s

Faci

lity

leve

l tra

inin

g an

d m

ento

rshi

o fo

r IPT

impl

emen

ting

sit

es in

all

hig

h an

d m

ediu

m b

urde

ned

coun

ties

Prin

t co

ntac

t tr

acin

g re

gist

ers

06,

000

2,00

00

Prin

t IC

F/IP

T ca

rds

Prin

t 5

00,0

00 I

CF/

IPT

card

sPr

int

500

,000

IC

F/IP

T ca

rds

Prin

t 5

00,0

00 I

CF/

IPT

card

s0

IPT

pati

ent

appo

intm

ent

card

sPr

int

200,

000

IPT

appo

intm

ent

card

sPr

int

200,

000

IPT

appo

intm

ent

card

sPr

int

200,

000

IPT

appo

intm

ent

card

s0

IPT

regi

ster

Prin

t 20

00 IP

T r

egis

ters

0

Prin

t 2,

000

IPT

reg

iste

rs

0

Stra

tegi

c A

ppro

ach

4: S

cale

up

of T

B IP

C in

hea

lth

care

and

con

greg

ate

sett

ings

Num

ber

of

wor

ksho

ps

for

the

deve

lopm

ent

of T

B IP

C t

ools

and

pol

icy

guid

elin

es c

ondu

cted

Mul

ti-s

ecto

ral

stak

ehol

der'

s fo

rum

in

clud

ing

othe

r no

n-m

edic

al s

take

hold

ers

to

leve

rage

on

IP

C

supp

ort

by

othe

r m

inis

trie

s su

ch

as

Min

istr

y of

H

ousi

ng,

min

istr

y of

edu

cati

on.

1 w

orks

hop

4n/

an/

an/

an/

an/

an/

a

Dev

elop

TB/

HIV

wor

kpla

ce p

olic

y2

wor

ksho

psn/

an/

an/

a

Wor

k sh

op

to

revi

se

IPC

gu

idel

ines

, de

velo

pmen

t of

IPC

CQ

I and

IPC

indi

cato

rs

1 w

orks

hop

Num

ber

of

IPC

po

licy

docu

men

ts

and

tool

s pr

inte

dPr

int

TB/H

IV w

orkp

lace

doc

umen

ts6,

000

TB/

HIV

pol

icy

docu

men

ts

12,0

000

n/a

0n/

a0

n/a

Prin

t a

nd d

istr

ibut

e re

vise

d IP

C g

uide

lines

6,

000

IPC

gu

idel

ine

copi

es

prin

ted

00

0

Prop

orti

on

of

heal

th

faci

litie

s an

d co

ngre

gate

set

ting

s im

plem

enti

ng T

B IP

CD

isse

min

ate

IPC

gu

idel

ines

an

d TB

/HIV

w

orkp

lace

pol

icy

docu

men

t0

1 m

eeti

ng f

or c

oth

TB/H

IV p

olic

y an

d IP

C g

uide

line

diss

emin

atio

n25

%0

50%

050

%

Cou

nty

leve

l tr

aini

ngs

of

revi

sed

IPC

gu

idel

ines

01

trai

ning

/cou

nty

for

21

high

bu

rden

cou

ntie

s1

trai

ning

/cou

nty

for

19

mid

bu

rden

cou

ntie

s0

Con

duct

fac

ility

lev

el T

B in

fect

ion

trai

ning

an

d ri

sk a

sses

smen

ts0

Con

duct

TB

risk

ass

esm

ent

in 2

1 H

IV h

igh

prev

alnc

e co

unti

es (

7 he

alth

fac

iliti

es p

er c

ount

y)

00

Dev

elop

men

t of

faci

lity

leve

l IP

C

wor

k pl

ans

0D

evel

op h

ealt

h fa

cilit

y IP

C p

lans

in

21

HIV

hig

h pr

eval

ent c

ount

ies

(7 h

ealt

h fa

cilit

ies

per

coun

ty)

00

Stra

tegi

c A

ppro

ach

5: Im

med

iate

cA

RT

and

CPT

upt

ake

Prop

orti

on o

f H

IV p

osit

ive

TB p

atie

nts

put

on c

ART

Esta

blis

h eM

TCT

site

s as

cA

RT

prov

idin

g fa

cilit

ies

for

TB p

atie

nts

(NA

SCO

P)

80%

Esta

blis

h 65

0 eM

TCT

site

s as

cA

RT p

rovi

ding

sit

es85

%Es

tabl

ish

1,00

0 eM

TCT

site

s as

c

ART

pro

vidi

ng s

ites

90%

n/a

90%

Con

duct

3 n

atio

nal T

oT t

rain

ings

on

TB/H

IV

for

all c

ount

ies

TB/H

IV

ToT

trai

ning

s fo

r 10

0 To

Ts

(rep

rese

ntat

ives

fr

om

47co

unti

es)

n/a

n/a

n/a

Con

duct

cou

nty

leve

l HC

W t

rain

ings

on

TB/

HIV

0

21 c

ount

y TB

/HIV

tra

inin

gs f

or

35 p

arti

cpan

ts/c

ount

y 19

cou

nty

TB/H

IV t

rain

ings

for

35

part

icpa

nts/

coun

ty

n/a

Con

duct

fac

ility

lev

el m

ento

rshi

p of

car

e pr

ovid

ers

in T

B se

ttin

gs in

pro

visi

on o

f A

RT

0A

ll TB

cl

inic

s lo

cate

d in

si

tes

whe

re

ART

is

pr

ovid

ed

to

preg

nant

wom

en

All

TB

clin

ics

loca

ted

in

site

s w

here

ART

is p

rovi

ded

to p

regn

ant

wom

en

All

TB c

linic

s lo

cate

d in

sit

es w

here

A

RT is

pro

vide

d to

pre

gnan

t w

omen

Revi

sion

of

the

TB/H

IV g

uide

lines

, Ed

itin

g an

d fo

rmat

ting

of

revi

sed

TB/H

IV g

uide

lines

1 w

orks

hop,

co

ntra

ct

a co

nsul

tant

fo

r ed

itin

g an

d fo

rmat

ting

of

guid

elin

es

n/a

n/a

n/a

4.3.

5. M

ulti

-sec

tora

l Res

pons

e to

TB/

HIV

TB/H

IV O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Con

duct

co

unty

le

vel

IPT

sens

itiz

atio

ns

thro

ugh

impl

emen

ting

par

tner

s IP

T co

unty

lev

el s

ensi

tiza

tion

s fo

r 21

high

H

IV

bu

rden

co

unti

es

IPT

coun

ty

leve

l se

nsit

izat

ions

fo

r 19

cou

ntie

sn/

an/

a

Con

duct

fa

cilit

y le

vel

men

tors

hip

and

trai

ning

thr

ough

CH

MT

and

Impl

emen

ting

pa

rtne

rs

Faci

lity

leve

l tr

aini

ng

and

men

tors

hio

fo

r IP

T im

plem

enti

ng

site

s in

hi

gh

burd

ened

cou

ntie

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hio

for I

PT im

plem

enti

ng

site

s in

all

hig

h an

d m

ediu

m

burd

ened

cou

ntie

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hio

for

IPT

im

plem

enti

ng

site

s in

al

l

high

an

d m

ediu

m

burd

ened

cou

ntie

s

Faci

lity

leve

l tra

inin

g an

d m

ento

rshi

o fo

r IPT

impl

emen

ting

sit

es in

all

hig

h an

d m

ediu

m b

urde

ned

coun

ties

Prin

t co

ntac

t tr

acin

g re

gist

ers

06,

000

2,00

00

Prin

t IC

F/IP

T ca

rds

Prin

t 5

00,0

00 I

CF/

IPT

card

sPr

int

500

,000

IC

F/IP

T ca

rds

Prin

t 5

00,0

00 I

CF/

IPT

card

s0

IPT

pati

ent

appo

intm

ent

card

sPr

int

200,

000

IPT

appo

intm

ent

card

sPr

int

200,

000

IPT

appo

intm

ent

card

sPr

int

200,

000

IPT

appo

intm

ent

card

s0

IPT

regi

ster

Prin

t 20

00 IP

T r

egis

ters

0

Prin

t 2,

000

IPT

reg

iste

rs

0

Stra

tegi

c A

ppro

ach

4: S

cale

up

of T

B IP

C in

hea

lthc

are

and

cong

rega

te s

etti

ngs

Num

ber

of

wor

ksho

ps

for

the

deve

lopm

ent

of T

B IP

C t

ools

and

pol

icy

guid

elin

es c

ondu

cted

Mul

ti-s

ecto

ral

stak

ehol

der'

s fo

rum

in

clud

ing

othe

r no

n-m

edic

al s

take

hold

ers

to

leve

rage

on

IP

C

supp

ort

by

othe

r m

inis

trie

s su

ch

as

Min

istr

y of

H

ousi

ng,

min

istr

y of

edu

cati

on.

1 w

orks

hop

4n/

an/

an/

an/

an/

an/

a

Dev

elop

TB/

HIV

wor

kpla

ce p

olic

y2

wor

ksho

psn/

an/

an/

a

Wor

k sh

op

to

revi

se

IPC

gu

idel

ines

, de

velo

pmen

t of

IPC

CQ

I and

IPC

indi

cato

rs

1 w

orks

hop

Num

ber

of

IPC

po

licy

docu

men

ts

and

tool

s pr

inte

dPr

int

TB/H

IV w

orkp

lace

doc

umen

ts6,

000

TB/

HIV

pol

icy

docu

men

ts

12,0

000

n/a

0n/

a0

n/a

Prin

t a

nd d

istr

ibut

e re

vise

d IP

C g

uide

lines

6,

000

IPC

gu

idel

ine

copi

es

prin

ted

00

0

Prop

orti

on

of

heal

th

faci

litie

s an

d co

ngre

gate

set

ting

s im

plem

enti

ng T

B IP

CD

isse

min

ate

IPC

gu

idel

ines

an

d TB

/HIV

w

orkp

lace

pol

icy

docu

men

t0

1 m

eeti

ng f

or c

oth

TB/H

IV p

olic

y an

d IP

C g

uide

line

diss

emin

atio

n25

%0

50%

050

%

Cou

nty

leve

l tr

aini

ngs

of

revi

sed

IPC

gu

idel

ines

01

trai

ning

/cou

nty

for

21

high

bu

rden

cou

ntie

s1

trai

ning

/cou

nty

for

19

mid

bu

rden

cou

ntie

s0

Con

duct

fac

ility

lev

el T

B in

fect

ion

trai

ning

an

d ri

sk a

sses

smen

ts0

Con

duct

TB

risk

ass

esm

ent

in 2

1 H

IV h

igh

prev

alnc

e co

unti

es (

7 he

alth

fac

iliti

es p

er c

ount

y)

00

Dev

elop

men

t of

faci

lity

leve

l IP

C

wor

k pl

ans

0D

evel

op h

ealt

h fa

cilit

y IP

C p

lans

in

21

HIV

hig

h pr

eval

ent c

ount

ies

(7 h

ealt

h fa

cilit

ies

per

coun

ty)

00

Stra

tegi

c A

ppro

ach

5: Im

med

iate

cA

RT

and

CPT

upt

ake

Prop

orti

on o

f H

IV p

osit

ive

TB p

atie

nts

put

on c

ART

Esta

blis

h eM

TCT

site

s as

cA

RT

prov

idin

g fa

cilit

ies

for

TB p

atie

nts

(NA

SCO

P)

80%

Esta

blis

h 65

0 eM

TCT

site

s as

cA

RT p

rovi

ding

sit

es85

%Es

tabl

ish

1,00

0 eM

TCT

site

s as

c

ART

pro

vidi

ng s

ites

90%

n/a

90%

Con

duct

3 n

atio

nal T

oT t

rain

ings

on

TB/H

IV

for

all c

ount

ies

TB/H

IV

ToT

trai

ning

s fo

r 10

0 To

Ts

(rep

rese

ntat

ives

fr

om

47co

unti

es)

n/a

n/a

n/a

Con

duct

cou

nty

leve

l HC

W t

rain

ings

on

TB/

HIV

0

21 c

ount

y TB

/HIV

tra

inin

gs f

or

35 p

arti

cpan

ts/c

ount

y 19

cou

nty

TB/H

IV t

rain

ings

for

35

part

icpa

nts/

coun

ty

n/a

Con

duct

fac

ility

lev

el m

ento

rshi

p of

car

e pr

ovid

ers

in T

B se

ttin

gs in

pro

visi

on o

f A

RT

0A

ll TB

cl

inic

s lo

cate

d in

si

tes

whe

re

ART

is

pr

ovid

ed

to

preg

nant

wom

en

All

TB

clin

ics

loca

ted

in

site

s w

here

ART

is p

rovi

ded

to p

regn

ant

wom

en

All

TB c

linic

s lo

cate

d in

sit

es w

here

A

RT is

pro

vide

d to

pre

gnan

t w

omen

Revi

sion

of

the

TB/H

IV g

uide

lines

, Ed

itin

g an

d fo

rmat

ting

of

revi

sed

TB/H

IV g

uide

lines

1 w

orks

hop,

co

ntra

ct

a co

nsul

tant

fo

r ed

itin

g an

d fo

rmat

ting

of

guid

elin

es

n/a

n/a

n/a

4.3.5. Multi-sectoral Response to TB/H

IV

TB/H

IV O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on o

f H

IV p

osit

ive

TB p

atie

nts

put

on c

ART

Prin

ting

of

TB/H

IV g

uide

lines

Prin

t 6,

000

copi

es o

f re

vise

d gu

idel

ines

n/a

n/a

n/a

Hol

d na

tion

al

TB/H

IV

guid

elin

e di

ssem

inat

ion

mee

ting

1 m

eeti

ngn/

an/

an/

a

Hol

d C

ount

y le

vel

TB/H

IV

guid

elin

e di

ssem

inat

ion

mee

ting

s47

cou

ntie

sn/

an/

an/

a

Hol

d su

bcou

nty

and

Cou

nty

leve

l TB

/HIV

gu

idel

ine

diss

emin

atio

n m

eeti

ngs

Faci

lity

leve

l tr

aini

ng

and

men

tors

hip

on n

ew g

uide

lines

us

ing

impl

emen

ting

par

tner

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hip

on

new

gu

idel

ines

us

ing

impl

emen

ting

par

tner

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hip

on

new

gu

idel

ines

us

ing

impl

emen

ting

par

tner

s

Faci

lity

leve

l tr

aini

ng

and

men

tors

hip

on n

ew g

uide

lines

usi

ng

impl

emen

ting

par

tner

s

Hol

d a

thre

e da

y w

orks

hop

to

deve

lop

cont

ent

for

the

elec

tron

ic T

B/H

IV t

reat

men

t gu

idel

ines

1 m

eeti

ng

for

cont

ent

deve

lopm

ent

Dev

elop

a T

B/H

IV g

uide

lines

mob

ile a

ppC

ontr

act

cons

ulta

nt

to

crea

te m

obile

app

for

TB/

HIV

gu

idel

ines

n/a

n/a

n/a

Pilo

t th

e TB

/HIV

gui

delin

es m

obile

app

Supp

ort

site

vis

its

to p

ilot

site

s in

2 s

elec

ted

cou

ntie

sn/

an/

an/

a

Laun

ch m

obile

TB/

HIV

gui

delin

esN

ews

pape

r ad

vert

SMS

to

clin

icia

ns

nurs

es

and

othe

r pa

ctit

ione

rsn/

an/

a

4.3.6. Accelerate appropriate diagnosis1. Situational Analysis

Laboratory services play a key role in TB diagnosis, prevention and control in Kenya. Smear microscopy (both light and fluorescence), molecular techniques (Line Probe Assay and Xpert MTB/RIF) and culture (solid and liquid media) are all available in the country for TB and MDR TB diagnosis. Both the NTLD Program and the National TB Reference Laboratory (NTRL) coordinate diagnostic services, while a laboratory technical working group guides in implementation of TB laboratory services. TB diagnosis is embedded in various national guidelines.

Sputum smear microscopy has been the mainstay of TB diagnosis in Kenya. Smear microscopy is provided through a network of 1,860 laboratories embedded within the general health services. Of these labs, 70% are public, 20% faith-based organizations and 10% private sector. In terms of coverage, most hospitals (91%) and health centers (78%) have TB diagnostic capacity. At lower levels, only 20% of dispensaries and 15% of clinics offer TB diagnostic services. The coverage of sputum microscopy currently stands at 1 light microscope for 25,000 persons, which is above the WHO recommendation of 1:50,000. A map of the geographic distribution of laboratories shows continued barriers to access in remote areas. Following WHO’s policy recommendation in 2010, Xpert MTB/RIF assay was introduced in 2011 and has been rolled out to 70 facilities nationwide.

The laboratory network is divided into three levels i.e. periphery, intermediate and central levels, with different technologies available at different levels, as indicated in Figure 23 below.

a) Peripheral/Level I: Laboratories at this level perform microscopy using ZN or FM, depending on the workload. They refer specimens for GeneXpert to the intermediate level laboratories. Upon clinicians’ request, some of these sites refer specimens to the central level laboratories for culture and DST.

b) Intermediate/Level II: The county and sub-county laboratories are involved in the diagnosis of new cases/treatment follow-up using either ZN or FM. Some of the facilities are equipped with a GeneXpert instrument. Specimens from

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Figure 23: Laboratory Network Levels

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Map 10: Distribution of Smear Microscopy Sites by Population Density, 2013

all the retreatment cases are referred to the central level labs for further analysis.

c) Central/Level III: The NTRL performs solid culture (LJ), liquid culture (MGIT), drug susceptibility testing (DST) for 1st line drugs on liquid medium, microscopy (ZN & FM), LPA (R/H), GeneXpert and identification of M tuberculosis complex (MPT64). It is also involved in providing External Quality Assurance (EQA) for microscopy and technical assistance to county laboratories. Other facilities with culture and drug susceptibility testing (DST) capacity include KEMRI Kisian in Kisumu, IOM (Dadaab and Nairobi), Aga Khan and Nairobi hospitals, and KEMRI Nairobi. This translates to 0.75 per 5 million population.

A supranational reference laboratory, the Queensland Mycobacterial Reference Laboratory (QMRL) in Brisbane, Australia, provides technical assistance and training. It serves as the reference lab for proficiency testing (PT) for the NTRL.

2. Definition of opportunities for improvements, gaps/challenges that need to be addressed

a) Integrated Specimen referral: In 2010, a courier-based specimen referral system was initiated for routine surveillance of TB/MDR. In this system, specimens are delivered to the central level for culture and DST. This needs to be extended and decentralized to enable inter-county specimen referral.

b) Underutilization of Xpert: The Xpert MTB/RIF technology was recently adopted by the NTLD Program and the current utilization of the instruments stands at 20% of their capacity. Health care workers have not been adequately sensitized on the algorithm, availability of the services and the existing referral networks.

c) Delayed turnaround time (TAT): There is a delay in transmission of results from laboratories (mainly the NTRL) to clinicians. This is partly due to the delay in specimen transportation and the current system of result transmission through LIMS. Results are transmitted via email to the county and sub-county TB and Leprosy coordinators of the referring clinic, and do not reach the clinicians in good time.

d) Access to 2nd line DST: The NTRL is currently building capacity to test for 2nd line drug resistance.

e) EQA: About 88% of microscopy laboratories are covered under the national quality assurance scheme. The NTRL is enrolled in a proficiency testing program through the SRL in Brisbane, while the GeneXpert sites are enrolled in a CDC Atlanta-led PT scheme. This needs further expansion to ensure all sites are enrolled in an EQA program, and that feedback to participating laboratories is regular.

Figure 24: Laboratories Providing Sputum Smear Microscopy

4.3.6. Accelerate A

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f) Integration of LIMS with TIBU: The NTRL has a robust laboratory information management system (LIMS) for data management, while the NTLD Program recently developed a patient management system called TIBU. There is an opportunity to further strengthen patient management by linking these systems.

g) Operational research: There is a need to strengthen the capacity of laboratory personnel for operational research.

h) Weak biosafety and infection prevention measures: Due to lack of equipment, appropriate personal preventive equipment (PPE) and inadequate laboratory infrastructure, biosafety in TB laboratories remains a challenge.

i) Limited geographical access to diagnosis in remote areas: As reflected in the map above, many populations must travel long distances to access diagnostic facilities, potentially delaying diagnosis.

3. Strategic Direction(s) for 2015-2018

Priorities for the next three years include: a) Adoption, roll-out and scale-up of GeneXpert technology countrywide as a diagnostic tool for all symptomatic HIV-infected individuals, presumptive pediatric and MDR-TB cases, health care workers and symptomatic refugees; b) Review and adopt policy to include self-referral to the diagnostic lab of presumptive TB cases; c) Enhance quality and strengthen the existing culture labs; d) Develop capacity for 2nd line DST at NTRL; e) Scale-up INH DST for all Xpert/MTB Rif MTB positive cases; f) Scale-up of fluorescence microscopy from the current 150 to 340 for all facilities performing an average of >2 smears per day; g) Enhance biosafety and infection prevention control measures in TB laboratories.

Particular emphasis will be given to reducing the distance to diagnostic services for rural populations, as well as the time to receipt of results.

4. Proposed Approaches

Accelerate time to diagnosis, especially among rural populations

Support county-level mapping of distances to diagnostic facilities, with the aim of prioritizing the addition of rural sputum collection points and transport networks to facilitate patient diagnosis.

Roll out and scale up Xpert MTB/RIF

GeneXpert will be the primary diagnostic test for all symptomatic HIV-infected individuals, presumptive pediatric cases, symptomatic health care workers, symptomatic refugees (WHO guidelines, MOH HIV rapid advice June 2014) and smear negative patients with suggestive radiological features. The algorithm in Figure 25 will be printed and distributed to all facilities. Sensitisation of health care workers will be done through Continuous Medical Education (CMEs) and integrated in various trainings for surveillance. All previously treated patients, DR-TB contacts, patients developing TB on IPT and smear positive patients at 2 months shall also be screened using Xpert MTB/RIF. With recommendation from NTRL, the NPHLS will appoint a dedicated national GeneXpert Coordinator to take the lead in the formation and coordination of a TWG.

Scale-up of GeneXpert machines in congregate settings, such as prisons and housing for uniformed services and students, will be prioritized.

GeneXpert sites will be expanded to cover all county hospitals and 60% of sub-county hospitals by 2018. The placement will be based on workload, accessibility as well as mobile communities and congregate settings to ensure equitable distribution.

The number of GeneXpert equipment to be placed in the country by the end of 2018 is projected at 250. Monitoring and evaluation – The GeneXpert online reporting system will be installed in all the GeneXpert equipment and used to monitor utilization, quality of testing and quantify the commodities and error rates. The TWG will provide oversight and continuous monitoring of implementation through site visits and periodic review meetings. Performance of GeneXpert sites will be evaluated using a set of indicators adopted from WHO for local use.

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Figure 25: GeneXpert Testing Algorithim

4.3.6. Accelerate A

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_______________________________________________________________________________________________________________________________• WHO endorsed Xpert MTB/RIF in 2010 for rapid diagnosis of MTB and Rifampicin resistance as a proxy for MDR diagnosis (http://www.who.int/tb/features_archive/new_rapid_test/en/)

• A further policy update was published in 2013 to include extra pulmonary cases (http://www.who.int/tb/laboratory/policy_statements/en/)

• The national TB program has adopted Xpert MTB/RIF as initial test for HIV-infected individuals

• In Malaysia, case detection among prisoners was improved by use of Xpert. This supports scale-up of Xpert to congregate settings.

• The Diagnostic Performance of a Single GeneXpertMTB/RIF Assay in an Intensified Tuberculosis Case Finding Survey among HIV-Infected Prisoners in Malaysia: Haider Abdulrazzaq Abed Al-Darraji1et al

90                                                                                                                                                      

2. MDR TB surveillance

§ All previously treated patients: a. failures; b. relapses; c. treatment after loss to follow up • DR TB contacts • Healthcare workers with TB symptoms • Patients who develop TB on IPT • Refugees with symptoms of TB • Smear positive at 2 months • Prisoners with TB symptoms In areas where GeneXpert is available, this should be the first test. Patients diagnosed with GeneXpert should be followed up with microscopy

 

Indications for GeneXpert 1. TB Diagnosis

• HIV positive with TB symptoms • Children under 15 years with TB symptoms • All smear negative TB cases

Results of GeneXpert

TB positive and also Rifampicin resistance

TB positive but no resistance to Rifampicin

Patient has symptoms suggestive of TB but GeneXpert is negative for TB

Start on MDR TB treatment and ART if HIV positive

Send sample for culture & DST (First line and second line)

If any resistance for injectables and/or FQ –Discuss in MDR TB Clinical meeting for Individualized regimen. For PDR and mono-resistant TB, treat as per guidelines

If DST indicates resistance, treat as per PMDT guidelines

Do Sputum for Smear follow- up month 2/3 and 5

SS -ve SS +ve

Treatment success

X-ray, broad-spectrum antibiotics, clinical condition

Improvement; Continue and observe. If none consider other diagnosis and manage accordingly

Culture and DST and manage as per the MDR TB guidelines

For MDR TB surveillance group -Do culture & DST (Offer HIV testing) Treat with Cat I as per TB guidelines

For TB diagnosis (offer HIV testing) Treat with Cat I as per TB guidelines

If no resistance, continue treatment No

improvement and still TB suspect

Repeat GeneXpert for surveillance and also do culture and DST & manage as per the MDR TB guidelines

Networking of Xpert MTB/RIF machines

To ensure access for GeneXpert services, all counties should develop networking frameworks integrated with existing HIV CD4 networks and others. This is depicted in figure 26. GeneXpert sites should also develop secondary networks to ensure uninterrupted services in case of equipment breakdown.

TAT and results dissemination: The national TB program will optimize the use of electronic data tools, such as GXAlert on line reporting system and SMS printers to ensure quick TAT of GeneXpert results within 48 hours.

• Quality assurance: All Xpert testing sites shall be enrolled under a national quality assurance program coordinated by the NTRL.

• Logistics: Quantification, procurement and distribution of GeneXpert supplies will be centralized and coordinated by the national program. County governments will be engaged to provide equipment maintenance/service contracts and assured power supply for instruments at the county level.

• Public Private Partnerships: The NTLD Program will continue collaborating with private Xpert testing facilities to ensure all TB cases are reported to the national program and diagnostic algorithms are adhered to.

• Communication package: A standardized communication package for Xpert shall be developed to support the sensitization of HCWs on the use of Xpert. The package will also include information to be disseminated to presumptive TB patients.

There is need to pilot mobile GeneXpert services in learning institutions, marginalized, and migrant communities, with a vision for a wider roll-out and networking.

a) Enhancing quality and strengthening the existing culture capacity

Culture remains the gold standard for MTB diagnosis and drug susceptibility testing. The two existing public labs (NTRL and Kisumu Kisian) will be strengthened and their access and utilization optimized through enrolment in PT programs, better coordination and strengthened specimen referral networks.

Given the cost implications and complexity of establishing and maintaining culture labs and the thrust of Xpert MTB/RIF, which has increased access to accurate TB diagnosis and Rifampicin resistance testing, no scale-up toward more culture labs is planned within the strategic period. The NTRL will review standards for culture labs to guide facilities that are already offering culture services, in terms of research for future decentralization.

All patients with Rifampicin resistance results will be subjected to culture and DST, while patients on MDR-TB treatment will be subjected to culture for monitoring of treatment.

The sample referral mechanisms for culture samples via courier system will be continued to maintain quality.

Turnaround time of results will be monitored via MDR-TB suspect registers. At least 80% of the results feedback should be expected in one month. The LIMS should be linked to the TIBU system to ensure rapid result dissemination and improved patient management. Facilities with internet services will have their chest clinics and referral labs linked in order to have access to the results through LIMS. An evaluation of TAT will be conducted at NTRL and representative health facilities biannually, and the findings presented during the biannual county TB and Leprosy coordinators’ meetings.

To ensure quality of the existing culture labs, NTRL staff will receive capacity building and mentorship through regular training programs locally and regionally. The implementation of QMS towards accreditation (ISO 15189) and the strengthening of quality assurance measures will be enhanced at all levels, as well as regular participation in proficiency testing programs. A system to monitor NTRL essential equipment will be installed to alert the staff in case of breakdowns.

The national program shall support the maintenance and repair of NTRL’s infrastructure. County governments shall be

Figure 26: GeneXpert Networking

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Sample flow chart for Culture and DST

4.3.6. Accelerate A

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Figure 27: Sample flow chart for Culture and DST

92

  Specimen reception

Rejection/Acceptance criteria

Accepted Rejected

AFB smear

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hours Culture L-J Culture/Primary

MGIT

Growth

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Smear Negative

Smear Positive

Give preliminary feedback within 48

hours

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Give preliminary feedback within 48

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Give feedback within 48 hours

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other kits

Give feedback within 48 hours Susceptible SIRE MGIT

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Resistant to R&I

Discordant results repeat MGIT DST MDR, 2nd Line DST

No MTB MTB

responsible for supporting infrastructural maintenance and repair for culture labs at the county level.

b) Scale up INH DST for all MTB positive retreatment cases

Within 2015-2017, the treatment regimen for retreatment cases will be guided by sensitivity of medications. Streptomycin will not be in the treatment option. Therefore, all MTB positive samples from retreatment patients will be subjected to culture and DST at the culture lab to rule out resistance to other drugs. In order to improve TAT, samples will be subjected to LPA to check INH sensitivity. Unpublished data from culture and DST showed INH mono-resistance of 5.5% (86 samples out of 1,545) via culture during the Jan-Dec 2013 period.

c) Developing capacity for 2nd line DST at NTRL

For all newly diagnosed MDR-TB patients, second line testing will be performed in order to identify early resistance. Currently, both the equipment and reagents for second line testing are available, but training is needed to enable staff to perform the tests routinely.

d) Scale up of LED microscopy

Smear microscopy remains the mainstay for TB diagnosis at the periphery level and for monitoring of treatment for drug-sensitive TB. In line with WHO recommendations, 150 LED microscopes were distributed between 2012 and 2013 to high volume laboratories. This will be expanded from current 150 sites to 340 by 2017. The LED microscopes will be placed in sites with an average of 2 smears per day and more.

All microscopy sites shall be enrolled into the national EQA program to ensure high quality services. The national program shall implement the existing capacity building plan for microscopy, including refresher and biosafety training. County governments will be engaged to build capacity for microscopy sites.

To improve access, all microscopy diagnostic sites will be networked to facilitate communication between health facilities and to enable referral of specimens from sites without microscopy equipment.

The county governments will be engaged to provide annual equipment maintenance for microscopes and conduct infrastructural upgrades on microscopy diagnostic sites to ensure adequate infection control and prevention measures. WHO-approved TB hoods shall be provided to high volume microscopy sites.

Logistics: Quantification, procurement and distribution of light and LED microscopy supplies will be centralized and coordinated by the NTLD Program.

Communication: The NTLD Program shall develop a communication and sensitization strategy for HCWs and for presumptive TB cases to create demand for smear microscopy.

Scale-up of light microscopes and the opening of new diagnostic facilities will be considered for hard to reach areas, guided by the GIS distribution of labs.

e) Enhancing biosafety and infection prevention in TB laboratories

Infection prevention control (IPC) for TB laboratory workers will be ensured through capacity building, provision of personal protective equipment (PPE), infrastructure upgrades, continuous screening of health care workers, proper waste management and proper documentation of those infected with TB.

The NTLD Program and NTRL shall develop an operational plan and accompanying policies to reinforce biosafety and infection control capacity and activities in health facilities and laboratories. The policies will ensure appropriate health facility and laboratory designs (adequate space, waiting areas and sputum collection booths) for each level, provision of TB hoods and biosafety cabinets, autoclaves and incinerators for waste management, and PPE (N95 masks). Additionally, the policies will outline a biosafety audit plan as well as an annual capacity building plan.

County Levela) Human resources: The NTLD Program and the NTRL shall lobby county governments to ensure adequate human

resources for all laboratories.

b) Capacity development: The NTLD Program and the NTRL will build capacity of the county TB laboratory coordinators on leadership and management, M&E, EQA, infection prevention and control and commodity management.

c) EQA: The NTLD Program and the NTRL shall lobby (and provide advice to) county governments to ensure adequate funds for sputum microscopy EQA activities.

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Contribution to NSP Impacts Outcomes (Laboratory)

Impact 1. Reduce the incidence of TB by 5% by 2018, compared to 2014

80% of TB patients (all forms) diagnosed within 2 weeks of initial care seeking

Impact 1.1 Reduce the prevalence of MDR-TB among new patients by 15%, by 2018

At least 30% of estimated INH-resistant cases are identified

At least 80% of culture and DST sample results received within a turn-around time of 60 days

Table 12: Outcome and Impact Indicators for Appropriate Diagnosis

4.3.6. Accelerate A

ppropriate Diagnosis

d) Infection control: The NTRL and NTLD Program will provide advice and lobby county governments to strengthen the infection control measures through capacity building, provision of appropriate biosafety equipment and infrastructure development.

Operational Research a) Conduct research to evaluate the impact and cost effectiveness of Xpert and online reporting system.

b) Undertake longitudinal data analysis of smear microscopy EQA to determine quality improvement trends and recurrent gaps.

c) Peform longitudinal data analysis on culture and DST services to determine trends, efficacy and effectiveness.

94

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etw

orki

ng o

f pu

blic

cu

ltur

e la

bs

thro

ugh

LIM

S

100%

Net

wor

king

of

pu

blic

cu

ltur

e la

bs

thro

ugh

LIM

S

100%

Net

wor

king

of

pu

blic

cu

ltur

e la

bs t

hrou

gh L

IMS

10

0%

Prop

orti

on

of

plan

ned

TWG

m

eeti

ngs

conv

ened

Form

TW

G

for

all

cult

ure

labs

(Pub

lic a

nd p

riva

te)

Form

TW

G f

or c

ultu

re

labs

C

ondu

ct

sem

i-an

nual

TW

G m

eeti

ngs

100%

Con

duct

se

mi-

annu

al

TWG

mee

ting

s10

0%C

ondu

ct

sem

i-an

nual

TW

G m

eeti

ngs

100%

4.3.

6. A

ccel

erat

e A

ppro

pria

te D

iagn

osis

Acc

eler

ate

App

ropr

iate

Dia

gnos

is O

pera

tion

al P

lan

Stra

tegi

c Pr

iori

ties

Stra

tegi

c A

ppro

ache

sO

utpu

t In

dica

tor(

s)A

ctiv

ity

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

2: S

tren

gthe

n ex

isti

ng q

ualit

y as

sura

nce

prog

ram

Stre

ngth

en

EQA

fo

r sp

utum

m

icro

scop

y fo

r bo

th l

ight

and

fl

uore

scen

ce m

etho

ds

Prop

orti

on

of

mic

rosc

opy

labo

rato

ries

wit

h at

lea

st 1

sta

ff

trai

ned

on E

QA

Trai

ning

of

mic

rosc

opy

labs

on

EQ

A

TOT

trai

ning

of

47

C

MLT

s on

EQ

An/

aBu

ild E

QA

cap

acit

y of

55

mic

rosc

opy

site

s25

Build

EQ

A

capa

city

of

55

mic

rosc

opy

site

s50

Build

EQ

A c

apac

ity

of 5

5 m

icro

scop

y si

tes

100

Prop

orti

on

of

mic

rosc

opy

labs

pa

rtic

ipat

ing

in q

uart

erly

EQ

ATO

T of

Cou

nty

med

ical

Lab

s on

EQ

A

Build

EQ

A c

apac

ity

of

55 m

icro

scop

y si

tes

90C

ondu

ct

refr

eshe

r tr

aini

ng f

or 1

25 M

LTs

>90

Con

duct

re

fres

her

trai

ning

for

125

MLT

s >

90C

ondu

ct r

efre

sher

tra

inin

g fo

r 12

5 M

LTs

>90

Con

duct

re

fres

her

trai

ning

on

EQ

A

Con

duct

re

fres

her

trai

ning

for

125

MLT

s C

ondu

ct

EQA

fo

r 10

0%

of

enro

lled

site

s

Con

duct

EQ

A f

or 1

00%

of

enr

olle

d si

tes

C

ondu

ct E

QA

for

100

% o

f en

rolle

d si

tes

Con

duct

mic

rosc

opy

EQA

Con

duct

EQ

A

for

100%

of

en

rolle

d si

tes

Proc

urem

ent

of 2

,500

slid

e bo

xes

Proc

urem

ent

of 2

,500

sl

ide

boxe

s

Pr

ocur

emen

t of

2,5

00

slid

e bo

xes

Proc

urem

ent

of

2,50

0 sl

ide

boxe

s

Proc

urem

ent

of

2,50

0 sl

ide

boxe

s

Impl

emen

tati

on

of

QM

S to

war

ds

accr

edit

atio

n an

d st

reng

then

ing

qual

ity

assu

ranc

e m

easu

res,

at

all l

evel

s.

NTR

L at

tain

s IS

O

1518

9 ac

cred

itat

ion

Trai

ning

of

N

TRL

staf

f on

Q

MS

Trai

ning

of

5

NTR

L st

aff

on Q

MS

n/

aTr

aini

ng

of

5 N

TRL

staf

f on

QM

S

n/a

Trai

ning

of

5 N

TRL

staf

f on

QM

S

n/a

Con

duct

m

anag

emen

t re

view

mee

ting

n/a

Con

duct

NTR

L au

dit

Revi

sion

of

N

TRL

docu

men

ts

Con

duct

man

agem

ent

revi

ew m

eeti

ngC

ondu

ct

man

agem

ent

revi

ew m

eeti

ng

Con

duct

m

anag

emen

t re

view

mee

ting

Con

duct

man

agem

ent

revi

ew m

eeti

ngC

ondu

ct a

udit

(K

ENA

S/SA

NA

S)

Con

duct

au

dit

(KEN

AS/

SAN

AS)

3: S

usta

in

com

mod

ity

man

agem

ent

Ensu

re

tim

ely

fore

cast

ing

and

quan

tifi

cati

on

of

all

com

mod

itie

s ar

e do

ne

Prop

orti

on

of

labs

re

port

ing

no

stoc

k ou

t fo

r co

mm

odit

ies

Con

duct

F&

Q m

eeti

ngC

ondu

ct F

&Q

mee

ting

100%

Con

duct

F&

Q m

eeti

ng10

0%C

ondu

ct F

&Q

mee

ting

100%

Con

duct

F&

Q m

eeti

ng10

0%

Proc

ure

AFB

, G

XPE

RT,

LPA

an

d cu

ltur

e Pr

ocur

e A

FB,

GX

PERT

, LP

A a

nd c

ultu

re

Proc

ure

AFB

, G

XPE

RT,

LPA

and

cul

ture

Pr

ocur

e A

FB,

GX

PERT

, LP

A a

nd c

ultu

re

Proc

ure

AFB

, G

XPE

RT,

LPA

an

d cu

ltur

e

Dis

trib

ute,

A

FB,

GX

pert

, LP

A,

cult

ure

and

DST

co

mm

odit

ies

Dis

trib

ute,

A

FB,

GX

pert

, LP

A,

cult

ure

and

DST

com

mod

itie

s

Dis

trib

ute,

A

FB,

GX

pert

, LP

A,

cult

ure

and

DST

com

mod

itie

s

Dis

trib

ute,

AFB

, G

Xpe

rt,

LPA

, cu

ltur

e an

d D

ST

com

mod

itie

s

Dis

trib

ute,

A

FB,

GX

pert

, LP

A,

cult

ure

and

DST

co

mm

odit

ies

De

ve

lo

p/

re

vi

ew

co

nsum

ptio

n da

ta t

ools

De

ve

lop

/re

vie

w

cons

umpt

ion

data

to

ols

4: S

cale

up

of

rapi

d m

olec

ular

TB

diag

nost

ics

Use

of

X

pert

as

fi

rst

line

diag

nosi

s fo

r H

IV-i

nfec

ted

pers

ons,

pre

sum

ptiv

e pa

edia

tric

ca

ses,

he

alth

ca

re

wor

kers

, sm

ear-

nega

tive

ra

diol

ogic

al

sugg

esti

ve

case

s an

d sy

mpt

omat

ic r

efug

ees

Prop

orti

on

of

targ

eted

ca

ses

rece

ivin

g X

pert

re

sult

s (d

isag

greg

ated

by

type

of

case

)

Mee

ting

to

Re

vise

of

di

agno

stic

alg

orit

hm

M

eeti

ng t

o Re

vise

of

diag

nost

ic a

lgor

ithm

Prin

ting

of

4,

000

diag

nost

ic a

lgor

ithm

s 50

% f

or e

ach

type

Trai

ning

of H

WC

s on

use

of

Xpe

rt75

%

for

each

typ

eTr

aini

ng o

f H

WC

s on

use

of

Xpe

rt>

85%

fo

r ea

ch t

ype

Prin

ting

of

di

agno

stic

al

gort

ithm

Prin

ting

of

2,

000

diag

nost

ic a

lgor

ithm

s D

istr

ibut

ion

of 4

,000

di

agno

stic

alg

orit

hms

Dis

trib

utio

n of

di

agno

stic

al

gori

thm

D

istr

ibut

ion

of 2

,000

di

agno

stic

alg

orit

hms

Tr

aini

ng o

f H

CW

s on

us

e of

Xpe

rt

4.3.6. Accelerate A

ppropriate Diagnosis

Acc

eler

ate

App

ropr

iate

Dia

gnos

is O

pera

tion

al P

lan

Stra

tegi

c Pr

iori

ties

Stra

tegi

c A

ppro

ache

sO

utpu

t In

dica

tor(

s)A

ctiv

ity

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Trai

ning

of

HC

Ws

on u

se o

f X

pert

Trai

ning

of

150

HC

Ws

on u

se o

f X

pert

Ensu

re s

yste

mat

ic r

ollo

ut a

nd

utili

zati

on o

f X

pert

MTB

/RIF

tes

t fo

llow

ing

nati

onal

pol

icie

s an

d gu

idel

ines

Incr

ease

d X

pert

sit

es f

rom

cur

rent

70

to

250

by 2

017

Map

ping

of

Xpe

rt s

ites

Map

ping

of X

pert

sit

es70

Map

ping

of X

pert

sit

es14

0M

appi

ng o

f X

pert

sit

esn/

aM

appi

ng o

f X

pert

sit

es25

0

Perc

enta

ge

incr

ease

in

th

e ut

iliza

tion

of

Xpe

rt

Pr

ocur

emen

t an

d in

stal

lati

on

of

Xpe

rt

inst

rum

ents

Proc

urem

ent

and

inst

alla

tion

of

50

GX

IV in

stru

men

ts

25%

Proc

urem

ent

and

inst

alla

tion

of

30

GX

IV in

stru

men

ts

50%

Proc

urem

ent

and

inst

alla

tion

of

50

GX

IV

inst

rum

ents

80%

Proc

urem

ent

and

inst

alla

tion

of

50

GX

IV

inst

rum

ents

>80

%

100%

of X

pert

faci

litie

s w

ith

acce

ss

to a

nd u

sing

onl

ine

repo

rtin

g

Proc

urem

ent

of m

odem

s fo

r X

pert

inst

rum

ents

Pr

ocur

emen

t of

50

m

odem

s fo

r X

pert

in

stru

men

ts

Proc

urem

ent

of

30

mod

ems

for

Xpe

rt

inst

rum

ents

Proc

urem

ent

of

50

mod

ems

for

Xpe

rt

inst

rum

ents

Proc

urem

ent

of

50

mod

ems

for

Xpe

rt

inst

rum

ents

100%

Trai

ning

of

HC

Ws

on u

se o

f on

line

repo

rtin

g to

ol

Trai

ning

of

240

MLT

s on

onl

ine

repo

rtin

g

Trai

ning

of

60 M

LTs

on

onlin

e re

port

ing

Tr

aini

ng o

f 10

0 M

LTs

on

onlin

e re

port

ing

Tr

aini

ng o

f 10

0 M

LTs

on

onlin

e re

port

ing

Ensu

re s

cale

up

of I

NH

DST

for

al

l Xpe

rt M

TB p

osit

ive

case

s Pr

opor

tion

of

Xpe

rt M

TB p

osit

ive

case

s w

ith

INH

DST

res

ults

Perf

orm

27,

000

test

sPe

rfor

m 6

,000

tes

ts25

Perf

orm

6,5

00 t

ests

50Pe

rfor

m 7

,000

tes

ts75

Perf

orm

7,5

00 t

ests

100

5: S

cale

up

of

mic

rosc

opy

serv

ice

Dec

entr

aliz

atio

n of

flu

ores

cent

m

icro

scop

y ce

ntre

s in

sit

es w

ith

>2

smea

rs p

er d

ay

Num

ber

of L

ED m

icro

scop

es in

use

Proc

urem

ent

of

190

LED

m

icro

scop

es

Proc

urem

ent

of

90

LED

mic

rosc

opes

14

0Pr

ocur

emen

t of

50

LE

D m

icro

scop

es

190

Proc

urem

ent

of 5

0 LE

D

mic

rosc

opes

24

024

0

Prop

orti

on o

f si

tes

wit

h >

2 sm

ears

pe

r da

y pe

rfor

min

g FM

Trai

ning

of

La

b pe

rson

nel

on F

M

Tr

aini

ng

of

50

Lab

pers

onne

l on

FM

Tr

aini

ng

of

50

Lab

pers

onne

l on

FM

25

%Tr

aini

ng

of

50

Lab

pers

onne

l on

FM

30

%50

%

Inst

alla

tion

of

ne

wly

pr

ocur

ed L

ED m

ocro

scop

esIn

stal

lati

on

of

90

proc

ured

LE

D

moc

rosc

opes

inst

alla

tion

of

50

pr

ocur

ed

LED

m

ocro

scop

es

inst

alla

tion

of

50

pr

ocur

ed

LED

m

ocro

scop

es

Dec

entr

aliz

atio

n of

lig

ht

mic

rosc

opy

serv

ices

in

hard

to

reac

h ar

eas

and

Cou

ntie

s w

ith

<1

mic

rosc

opy

site

per

50,

000

popu

lati

on

Prop

orti

on

of

coun

ties

w

ith

<1

mic

rosc

opy

site

pe

r 50

,000

po

pula

tion

Esta

blis

h at

lea

st 3

sm

ear

mic

rosc

opy

labs

in

12

pr

iori

ty

coun

ties

(T

urka

na,

Mar

sabi

t,

Gar

issa

, W

ajir,

Ba

ring

o,

Tana

Ri

ver,

Kit

ui,

Man

dera

, M

omba

sa,

Kw

ale,

K

ilifi

and

Lam

u)

Esta

blis

h at

le

ast

1 sm

ear

mic

rosc

opy

labs

in

12

pr

iori

ty

coun

ties

(T

urka

na,

Mar

sabi

t,

Gar

issa

, W

ajir,

Ba

ring

o,

Tana

Ri

ver,

Kit

ui,

Man

dera

, M

omba

sa,

Kw

ale,

K

ilifi

and

Lam

u)

Esta

blis

h at

le

ast

1 sm

ear

mic

rosc

opy

labs

in

12

pr

iori

ty

coun

ties

(T

urka

na,

Mar

sabi

t,

Gar

issa

, W

ajir,

Ba

ring

o,

Tana

Ri

ver,

Kit

ui,

Man

dera

, M

omba

sa,

Kw

ale,

K

ilifi

and

Lam

u)

25Es

tabl

ish

at

leas

t 1

smea

r m

icro

scop

y la

bs

in 1

2 pr

iori

ty c

ount

ies

(Tur

kana

, M

arsa

bit,

G

aris

sa,

Waj

ir, B

arin

go,

Tana

Ri

ver,

Kit

ui,

Man

dera

, M

omba

sa,

Kw

ale,

Kili

fi a

nd L

amu)

50Es

tabl

ish

at l

east

1 s

mea

r m

icro

scop

y la

bs

in

12

prio

rity

cou

ntie

s (T

urka

na,

Mar

sabi

t,

Gar

issa

, W

ajir,

Ba

ring

o, T

ana

Rive

r, K

itui

, M

ande

ra,

Mom

basa

, K

wal

e, K

ilifi

and

Lam

u)

100

Proc

ure

and

inst

all

light

m

icro

scop

es

Proc

ure

and

inst

all

48

light

mic

rosc

opes

Trai

n la

b pe

rson

nel o

n FM

Trai

n la

b pe

rson

nel

on F

M

4.3.

6. A

ccel

erat

e A

ppro

pria

te D

iagn

osis

Acc

eler

ate

App

ropr

iate

Dia

gnos

is O

pera

tion

al P

lan

Stra

tegi

c Pr

iori

ties

Stra

tegi

c A

ppro

ache

sO

utpu

t In

dica

tor(

s)A

ctiv

ity

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

6: Im

prov

ing

acce

ss

to q

ualit

y TB

di

agno

stic

s

Stre

ngth

en

spec

imen

re

ferr

al

netw

orks

Pr

opor

tion

of

pr

esum

ptiv

e M

DR-

TB p

atie

nts

wit

h cu

ltur

e an

d D

ST

resu

lts

docu

men

ted

Con

duct

sp

ecim

en

refe

rral

ne

twor

king

mee

ting

Con

duct

10

spec

imen

re

ferr

al

netw

orki

ng

mee

ting

100%

Con

duct

10

spec

imen

re

ferr

al

netw

orki

ng

mee

ting

100%

Con

duct

10

sp

ecim

en

refe

rral

ne

twor

king

m

eeti

ng

100%

Con

duct

10

sp

ecim

en

refe

rral

ne

twor

king

m

eeti

ng

100%

Proc

ure

stan

dard

spe

cim

en

colle

ctio

n,

pack

agin

g an

d tr

ansp

orta

tion

com

mod

itie

s

Proc

ure

20,0

00

zip

lock

bag

s an

d 4,

000

cool

box

es

Proc

ure

20,0

00

zip

lock

bag

s

Pr

ocur

e 20

,000

zip

lock

ba

gs

Pr

ocur

e 20

,000

zi

p lo

ck

bags

Con

duct

tr

aini

ng

of

HC

Ws

on

spec

imen

co

llect

ion,

pa

ckag

ing

and

tran

spor

tati

on

Con

duct

TO

T on

sp

ecim

en

tran

spor

tati

on f

or 9

4 H

CW

s

Con

duct

sp

ecim

ent

tran

spor

tati

on

Con

duct

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4.3.6. Accelerate A

ppropriate Diagnosis

Acc

eler

ate

App

ropr

iate

Dia

gnos

is O

pera

tion

al P

lan

Stra

tegi

c Pr

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ppro

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t In

dica

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ctiv

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4 Ta

rget

7:

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4.3.

6. A

ccel

erat

e A

ppro

pria

te D

iagn

osis

4.3.7 Ensure a stable and quality supply of medicines, diagnostics and other commodities 1. Situational Analysis

Since 2008, the Government of Kenya has been allocating funds for the procurement of TB medicines and diagnostics, complemented by donor support. Prior to devolution, forecasting and quantification was done nationally by the NTLD Program in collaboration with technical partners. A procurement plan was developed and reviewed bi-annually. A centralized and competitive procurement mechanism was implemented through Kenya Medical Supplies Agency (KEMSA) for first-line drugs. Second-line drugs for PMDT were supplied through the Global Drug Facility (GDF), with direct procurement. The whole process from quantification, advertising for tender, submission of bids, evaluation, contract negotiation and signing to the time the TB medicines arrived in the country took about nine months.

KEMSA handled the clearing and warehousing of medicines and diagnostics in collaboration with NTLD Program. The medicines were distributed to 210 district stores countrywide on a quarterly basis. From the district stores, the commodities were supplied on a monthly basis to the treatment sites using a collection system, facilitated by the SCTLC. An electronic LMIS system was used to collect consumption data, which was then aggregated on a monthly basis at the national level for planning purposes. There was a quality assurance mechanism at each level of the supply chain, including pharmacovigilance for TB medicines at service delivery points. A post-market surveillance was last conducted in 2009 to check on the quality of medicines used by TB patients at the service delivery points.

To ensure that adequate quantities of TB medicines are maintained, the NTLD Program has set minimum- maximum stocks to be kept at each level. For instance, a sub-county level maximum stock level is six months and minimum stock level is three months. Meanwhile, health facilities are required to maintain a maximum of three months of stocks and a minimum of one month of stock. A 12-month buffer for all medicines and diagnostics is to be maintained at the national warehouse for both first- and second-line medicines.

There is a TB logistic management system (LMIS), which provides integrated commodity recording and reporting tools, including electronic and paper based monthly reporting forms for use at sub-county and health facility level respectively. There is also a facility dispensing register and stock cards. A functional TB commodity security sub-committee is in place at the national level. The committee provides an oversight role in the implementation of TB commodity management activities, including monthly stock status monitoring, forecasting, and procurement planning. A pharmacovigilance system hosted by the Pharmacy and Poisons Board of Kenya exists, and adverse events reporting tools are in place.

In 2013, as part of devolution, the national government funds for procurement of TB medicines and diagnostics were devolved to county governments. County governments now have a mandate to procure TB medicines and diagnostics. However, no counties procured TB medicines and diagnostics in the 2013/14 fiscal year. Procurement of second line TB medicines remains primarily donor-supported, and has not been affected by the devolution of funds. The counties are in the process of streamlining their systems. However, the NTLD Program will continue to ensure a steady supply by liasing with government and other partners.

Other challenges identified by the mid-term review included weaknesses in commodity management practices, delayed deliveries, no order requisitions made, lack of capacity to enable the pull system, and receipts of medicines by non-pharmaceutical personnel. The distribution challenges may be a direct result of the low LMIS reporting rates, inaccurate consumption reports from SDP points, and lack of pharmaceutical personnel involvement at peripheral levels. In addition, there is inadequate capacity of storage facilities at the sub-county level and poor inventory management practices. Weak pharmacovigilance systems means that adverse drug reactions (ADRs) are rarely reported.

2. Strategic Direction(s) for 2015-2018

The priority is to ensure that no drug shortages occur at any level of the health system during the period of the NSP. The strategic direction for this period will aim to ensure a stable and quality-assured supply of drugs and diagnostics nationwide. Specifically, the strategic directions are to:

a) Build political commitment at central and in all 47 counties for funding of TB medicines and diagnostics.b) Strengthen the capacity of counties to appropriately plan for, procure, store, distribute and manage inventories of

commodities.c) Improve the distribution system, including the integration of laboratory diagnostics.d) Strengthen and link the existing DHIS, TIBU and LMIS systems for better management of supplies.e) Ensure quality of TB medicines and diagnostics in the country and in each county. f) Establish commodity security committees at county level.

4.3.7. Medicines, D

iagnostics and Other Com

modities

100

3. Proposed Approaches The approaches highlighted below aim to ensure availability of the following: First and second-line drugs to treat TB; INH to support scale-up of IPT; anti-leprosy drugs; PAL-related commodities for lung health; and ancillary medication to manage TB treatment side effects. The approaches include:

Increase political commitment and government funding for TB, leprosy and lung health medicines and diagnostics, from both national and county budgets

The NSP calls for increasing national government allocation to procure TB medicines and diagnostics, including for DR-TB, from 2014/2015 onwards. The government will also allocate more funds for services related to procurement of TB medicines e.g. customs clearance, warehousing, distribution, quality assurance activities and drug management activities. The planning for complementary funding for procurement and supply management (PSM); i.e. to fill funding gaps using Global Fund and other donor resources is prioritized.

Pooled and centralized procurement of TB medicines and diagnostics, involving all counties, to assure quality and benefit from economies of scale

To ensure high-quality and the lowest costs, bulk procurement at central level is the most efficient modality for maintaining a consistent and high-quality national supply. A 12-month buffer stock at national level will be restored and sustained. The NSP recognizes that this transition to county-level PSM will require technical assistance and new tools to build capacity and ensure consistent procurement planning. In addition, technical assistance is required at the central level to improve distribution systems and efficiency with devolved quantification. Mechanisms for emergency procurement of TB and other medicines and diagnostics will be developed.

Increase county capacity to manage the supply chain for TB, leprosy and lung health medicines and diagnostics

Capacity building of county staff, especially pharmacists, will be carried out through training in TB commodity management and regular supervisory visits that deliberately focus on commodities. Pharmacists will take charge of TB, leprosy and lung health medicines and diagnostics management. New tools will be developed to support county-level quantification and management, based on past use. Inventory management tools will be provided in every store or facilities providing commodities.

Figure 28: Commodities Management Framework

4.3.

7. M

edic

ines

, Dia

gnos

tics

and

Oth

er C

omm

odit

ies

101

4.3.7. Medicines, D

iagnostics and Other Com

modities

Rationalize and increase the efficiency of distribution and storage

Activities covered by this approach aim to maintain a steady supply of pharmaceuticals and supplies to facilities where they are needed, while ensuring that resources are being used in the most cost-effective way. This includes designation of demand-driven distribution points for TB medicines and diagnostics in all the 256 sub-counties, with accurate inventory records at all levels of the supply chain. Capacity will be strengthened at county level for distribution to sub-counties. Monitoring and mitigation of medicine loss caused by storage and expiry will be regularized. Targeted and systemic changes, including audits, will be implemented to reduce theft, fraud and leakage in the distribution system. Efforts will be made to accelerate port clearing, receipt and inspection of goods.

Strengthen the existing logistics management and information system (LMIS)

The existing TB Logistics Management Information System (LMIS) will be strengthened to facilitate better information flow and allow data-driven decision-making. Periodic data quality audits of LMIS are planned, including investigation and response to factors causing under-reporting; integration of stock-related data validation into quarterly review meetings; building capacity of counties and promote stock related data aggregation, analysis and use at county level for timely decision making. As noted in the M&E section of the NSP, the integration of DHIS, TIBU and LMIS platforms will be prioritized to facilitate monitoring across the continuum of service delivery. Monthly electronic reporting from all sub-counties will be monitored, enabling a monthly analysis of stock status and reporting rates by counties and nationally. All service delivery points will have requisite inventory & reporting tools.

Implement a comprehensive quality assurance program

• Implement and ensure devolution of procedures to ensure that only medicine products that meet current standards for quality are bought (careful product and supplier selection, certificate of analysis).

• Update procedures to verify that shipped goods meet the specifications (pre and post shipment inspection, analytical pharmaceutical testing).

• Update proper storage and distribution procedures, and provide guidance to and training for counties on these policies.

• Introduce product defect and pharmacovigilance reporting programs at county level. • Active surveillance for selected TB medicines will be explored. Regular post market surveillance is planned. To

support this revitalized focus on PSM, there will be activities to strengthen collaboration with the Pharmacy and Poisons Board of Kenya (PPB) to improve the pharmacovigilance system for TB by encouraging ADR surveillance and reporting.

Contribution to NSP Impacts Outcomes (Commodities)

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

100% of patients newly diagnosed with TB start treatment within two days

Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014

At least 80% of TB patients with Rif resistance are on 2nd line treatment within two weeks of testing.

Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014

• ]Increase to 90% the proportion of HIV+ TB patients accessing ART

• Increase to 90% the proportion of children with TB and HIV who are initiated on ART within two months of TB treatment initiation

• Increase to 80% the proportion of selected groups eligible for IPT to be enrolled on INH

Impact 2. Reduce mortality due to TB by 3% by 2018, compared to 2014

Ensure treatment success of at least 90% among all DS forms of TB

Impact 5. Reduce morbidity due to chronic lung diseases (e.g. COPD, asthma)

Increase to 80% the proportion of controlled asthma patients in areas with established PAL and asthma clinics

100% of commodities required to manage chronic lung diseases are available in each county

Enabling Environment: The NTLD Program and all counties have the required resources to implement the NSP

Nationally pooled and quality-assured drug supply is secured, with six-month buffer stock at central level for entire country

Table 13: Impact and Outcome Indicators for Medicines, Diagnostics and Other Commodities

102

4.3.

7. M

edic

ines

, Dia

gnos

tics

and

Oth

er C

omm

odit

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Com

mod

itie

s O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

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(s)

Yea

r 1

Act

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ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

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2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: B

uild

pol

itic

al c

omm

itm

ent

at c

entr

al a

nd in

all

47 c

ount

ies

for

fund

ing

of T

B, le

pros

y an

d lu

ng h

ealt

h m

edic

ines

and

dia

gnos

tics

Num

ber

of

Mee

ting

s w

ith

Cou

nty

Exec

utiv

es,

Cou

nty

Phar

mac

ist

fo

r re

sour

ce m

obili

zati

on a

ctiv

itie

s

Polit

ical

eng

agem

ent

of

lead

ers/

ke

y in

flue

ncer

s to

allo

cate

fund

ing

for

TB c

omm

odit

ies

and

logi

stic

s in

Nat

iona

l/ C

ount

y bu

dget

s

Mee

ting

w

ith

Cou

nty

Exec

utiv

es, C

ount

y Ph

arm

acis

t fo

r re

sour

ce

mob

iliza

tion

ac

tivi

ties

1M

eeti

ng

wit

h C

ount

y Ex

ecut

ives

, Cou

nty

Phar

mac

ist

for

reso

urce

m

obili

zati

on

acti

viti

es

1M

eeti

ng

wit

h C

ount

y Ex

ecut

ives

, C

ount

y Ph

arm

acis

t

for

reso

urce

m

obili

zati

on a

ctiv

itie

s

1M

eeti

ng w

ith

Cou

nty

Exec

utiv

es,

Cou

nty

Phar

mac

ist

fo

r re

sour

ce

mob

iliza

tion

ac

tivi

ties

1

Hol

d co

nsul

tati

ve

mee

ting

s to

lo

bby

for

incr

ease

d fu

ndin

g fo

r TB

m

edic

ines

an

d di

agno

stic

s,

fund

ing

for

serv

ices

re

late

d to

PS

M, f

undi

ng f

or lo

gist

ics

Mee

ting

s w

ith

CTL

Cs

and

othe

r pl

anne

rs t

o bu

dget

and

re

solv

e an

y in

form

atio

n ga

ps

2M

eeti

ngs

wit

h C

TLC

s an

d ot

her

plan

ners

2M

eeti

ngs

wit

h C

TLC

s an

d ot

her

plan

ners

2M

eeti

ngs

wit

h C

TLC

s an

d ot

her

plan

ners

2

Perc

enta

ge

of

all

fina

ncin

g fo

r TB

co

mm

odit

ies

fund

ed

by

nati

onal

go

vern

men

t

Trac

k fu

ndin

g fo

r TB

com

mod

itie

s th

roug

h TB

NH

A

Trac

k fu

ndin

g fo

r TB

co

mm

odit

ies

thro

ugh

TB N

HA

40

Trac

k fu

ndin

g fo

r TB

co

mm

odit

ies

thro

ugh

TB N

HA

45

Trac

k fu

ndin

g fo

r TB

co

mm

odit

ies

thro

ugh

TB

NH

A

50Tr

ack

fund

ing

for

TB c

omm

odit

ies

thro

ugh

TB N

HA

60

Stra

tegi

c A

ppro

ach

2: S

tren

gthe

n th

e ca

paci

ty o

f co

unti

es t

o ap

prop

riat

e pl

an f

or, p

rocu

re, s

tore

, dis

trib

ute

and

man

age

inve

ntor

ies

of c

omm

odit

ies

thro

ugh

a na

tion

ally

poo

led

syst

em

Num

ber

of

coun

ties

re

ceiv

eing

bi

-an

nual

tec

hnic

al a

ssis

tanc

e re

late

d to

su

pply

cha

in m

anag

emen

t

Tech

nica

l as

sist

ance

fro

m K

EMSA

, N

TLD

Pr

ogra

m

and

part

ners

to

co

unti

es

Con

duct

bi

an

nual

na

tion

al

leve

l TA

fo

cusi

ng

on

the

supp

ly c

hain

sys

tem

47C

ondu

ct

bi

annu

al

nati

onal

le

vel T

A fo

cusi

ng o

n th

e su

pply

ch

ain

syst

em

47C

ondu

ct

bi

annu

al

nati

onal

le

vel

TA

focu

sing

on

th

e su

pply

cha

in s

yste

m

47C

ondu

ct

bi

annu

al

nati

onal

le

vel

TA

focu

sing

on

the

supp

ly c

hain

sys

tem

47

Num

ber

of

coun

ties

us

ing

an

inte

grat

ed s

uppl

y ch

ain

for T

B, H

IV a

nd

Mal

aria

at

all l

evel

s

Inte

rgra

ted

dist

ribu

tion

of

TB

m

edic

ines

an

d la

bora

tory

co

mm

odit

ies

n/a

Inte

rgra

ted

dist

ribu

tion

of

TB

m

edic

ines

an

d la

bora

tory

co

mm

odit

ies

to a

ll 47

cou

ntie

s

47In

terg

rate

d di

stri

buti

on

of

TB m

edic

ines

and

lab

orat

ory

com

mod

itie

s to

al

l 47

co

unti

es

47In

terg

rate

d di

stri

buti

on o

f TB

med

icin

es

and

labo

rato

ry

com

mod

itie

s to

al

l 47

co

unti

es

47

Num

ber

of

join

t Fo

reca

stin

g an

d qu

anti

fica

tion

mee

ting

s he

ld b

etw

een

Nat

iona

l and

cou

nty

gove

rnm

ents

Supp

ort

a Jo

int

Nat

iona

l TB

Pr

ogra

m &

Cou

nty

Gov

ernm

ents

Fo

reca

stin

g &

Q

uant

ific

atio

n M

eeti

ngs

for

TB

Med

icin

es,

Labo

rato

ry

Con

sum

mab

les

incl

udin

g G

X R

IF C

artr

idge

s

Revi

se o

pera

tion

al p

roce

dure

s w

ith

KEM

SA F

& Q

mee

ting

s2

F &

Q m

eeti

ngs

2 F

& Q

mee

ting

s2

Num

ber

of c

ount

ies

wit

h co

sted

TB

com

mod

ity

proc

urem

ent

plan

sTr

aini

ng

of

Cou

nty

phar

mac

ists

,Cou

nty

TB

cord

inat

ors

and

Cou

nty

labo

rato

ry

cord

inat

ors

on

TB

com

mod

ity

man

agem

ent

Con

duct

tra

inin

g fo

r C

TLC

s47

Con

duct

tra

inin

g fo

r C

TLC

s47

Refr

eshe

r tr

aini

ng;

on-t

he-

job

tool

s47

Refr

eshe

r tr

aini

ng; o

n-th

e-jo

b to

ols

47

Dev

elop

tem

plat

es f

or e

stim

atin

g bu

dget

s an

d pr

ovid

e TA

to

co

unti

es

Dev

elop

te

mpl

ates

fo

r es

tim

atin

g bu

dget

s;

nati

onal

F

and

Q m

eeti

ng t

o de

term

ine

com

mod

ity

need

s

1F

and

Q m

eeti

ngs

at c

ount

y le

vel

to

dete

rmin

e th

e co

untr

y’s

TB c

omm

odit

y ne

eds

47F

and

Q m

eeti

ngs

at c

ount

y le

vel

to

dete

rmin

e th

e co

untr

y’s

TB

com

mod

ity

need

s

47F

and

Q

mee

ting

s at

co

unty

le

vel

to

dete

rmin

e th

e co

untr

y’s

TB

com

mod

ity

need

s

47

Prin

ting

an

d di

stri

buti

on

of

inve

ntor

y m

anag

emen

t t

ools

Prin

t an

d di

stri

bute

boo

klet

s fo

r A

FB o

f 10

0 pa

ges

3,60

0Pr

int

and

dist

ribu

te

book

lets

fo

r A

FB o

f 10

0 pa

ges

3,60

0Pr

int

and

dist

ribu

te b

ookl

ets

for

AFB

of

100

page

s3,

600

Prin

t an

d di

stri

bute

boo

klet

s fo

r A

FB o

f 10

0 pa

ges

3600

Tech

nica

l as

sist

ance

to

co

unti

es

on in

vent

ory

man

agem

ent

Tech

nica

l as

sist

ance

pro

vide

d by

NTL

D P

rogr

am,

Cen

ters

of

Exce

llenc

e (o

ther

cou

ntie

s), o

r pa

rtne

rs

47Te

chni

cal

assi

stan

ce p

rovi

ded

by N

TLD

Pro

gram

, C

ente

rs o

f Ex

celle

nce

(oth

er c

ount

ies)

, or

pa

rtne

rs

47Te

chni

cal a

ssis

tanc

e pr

ovid

ed

by N

TLD

Pro

gram

, Cen

ters

of

Exce

llenc

e (o

ther

co

unti

es),

or p

artn

ers

30Te

chni

cal

assi

stan

ce

prov

ided

by

N

TLD

Pr

ogra

m,

Cen

ters

of

Ex

celle

nce

(oth

er

coun

ties

), or

par

tner

s

30

Num

ber

of

coun

ties

w

ith

acti

ve

com

mod

ity

secu

rity

com

mit

tees

Form

co

mm

odit

y se

curi

ty

com

mit

tees

at

coun

ty le

vel

Prov

ide

tech

nica

l as

sist

ance

an

d tr

aini

ng

on

com

mod

ity

secu

rity

25Pr

ovid

e te

chni

cal

assi

stan

ce

and

trai

ning

on

co

mm

odit

y se

curi

ty

22Su

ppor

t co

mm

odit

y se

curi

ty

com

mit

tees

47Su

ppor

t co

mm

odit

y se

curi

ty c

omm

itte

es47

Num

ber

of

requ

ired

co

mm

odit

ies

proc

ured

Proc

ure

firs

t lin

e TB

dru

gs, S

econ

d Li

ne a

nti

TB m

edic

atio

n fo

r M

DR

TB-P

atie

nts,

XD

R TB

m

edic

ines

, A

ncill

ary

drug

s fo

r 3

25 p

atie

nts

Proc

ure

pati

ent

kits

100,

000

Proc

ure

pati

ent

kits

100,

000

Proc

ure

pati

ent

kits

100,

000

Proc

ure

pati

ent

kits

100,

000

4.3.7. Medicines, D

iagnostics and Other Com

modities

Com

mod

itie

s O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Proc

ure

ison

iazi

d fo

r TB

pr

even

tive

the

rapy

INH

pr

ocur

ed

(all

form

ulat

ions

)20

0,00

0IN

H p

rocu

red

(all

form

ulat

ions

)20

0,00

0IN

H

proc

ured

(a

ll fo

rmul

atio

ns)

200,

000

INH

pro

cure

d (a

ll fo

rmul

atio

ns)

200,

000

Pr

ocur

emen

t an

d su

pply

of

Tu

berc

ulin

Tu

berc

ulin

Sk

in

Test

Sy

ring

es

(sin

gle-

dose

di

spos

able

tu

berc

ulin

syr

inge

tha

t ha

s a

one-

quar

ter t

o on

e-ha

lf in

ch, 2

7-ga

uge

need

le w

ith

a sh

ort

beve

l)

Pro

cure

men

t an

d su

pply

of

Tube

rcul

in

Tube

rcul

in

Skin

Te

st

Syri

nges

(s

ingl

e-do

se

disp

osab

le t

uber

culin

syr

inge

th

at h

as a

one

-qua

rter

to

one-

half

in

ch,

27-g

auge

ne

edle

w

ith

a sh

ort

beve

l)

2,00

0Pr

ocur

emen

t an

d su

pply

of

Tu

berc

ulin

Tu

berc

ulin

Sk

in

Test

Sy

ring

es

(sin

gle-

dose

di

spos

able

tu

berc

ulin

sy

ring

e th

at h

as a

one

-qua

rter

to

one-

half

in

ch,

27-g

auge

ne

edle

w

ith

a sh

ort

beve

l)

2,00

0 P

rocu

rem

ent

and

supp

ly o

f Tu

berc

ulin

Tu

berc

ulin

Sk

in

Test

Sy

ring

es

(sin

gle-

dose

di

spos

able

tub

ercu

lin s

yrin

ge

that

ha

s a

one-

quar

ter

to

one-

half

in

ch,

27-g

auge

ne

edle

wit

h a

shor

t be

vel)

2,00

0 P

rocu

rem

ent

and

supp

ly o

f T

uber

culin

Tu

berc

ulin

Ski

n Te

st S

yrin

ges

(sin

gle-

dose

di

spos

able

tub

ercu

lin s

yrin

ge t

hat

has

a on

e-qu

arte

r to

on

e-ha

lf

inch

, 27

-gau

ge

need

le w

ith

a sh

ort

beve

l)

2000

Proc

ure

and

supp

ly r

ifab

utin

for

TB

-HIV

co-

infe

cted

pat

ient

s on

2nd

lin

e A

RT

Proc

ure

and

supp

ly r

ifab

utin

fo

r TB

-HIV

co

-inf

ecte

d pa

tien

ts o

n 2nd

line

ART

600

pati

ents

Proc

ure

and

supp

ly

rifa

buti

n fo

r TB-

HIV

co-

infe

cted

pat

ient

s on

2nd

line

ART

600

pati

ents

Proc

ure

and

supp

ly r

ifab

utin

fo

r TB

-HIV

co

-inf

ecte

d pa

tien

ts o

n 2nd

line

ART

600

pati

ents

Proc

ure

and

supp

ly r

ifab

utin

for

TB-

HIV

co

-inf

ecte

d pa

tien

ts o

n 2nd

line

ART

600

pati

ents

Proc

ure

lepr

osy

med

icin

ePr

ocur

e le

pros

y m

edic

ine

250

pati

ents

Proc

ure

lepr

osy

med

icin

e25

0 pa

tien

tsPr

ocur

e le

pros

y m

edic

ine

250

pati

ents

Proc

ure

lepr

osy

med

icin

e25

0 pa

tien

ts

Proc

ure

Labo

rato

ry c

onsu

mab

les

susp

ects

fo

r A

AFB

m

icro

scop

y,

cons

umab

les

for

Gen

e X

pert

Proc

ure

Labo

rato

ry

cons

umab

les

susp

ects

fo

r A

AFB

m

icro

scop

y,

cons

umab

les

for

Gen

e X

pert

Proc

ure

Labo

rato

ry

cons

umab

les

susp

ects

fo

r A

AFB

m

icro

scop

y,

cons

umab

les

for

Gen

e X

pert

Proc

ure

Labo

rato

ry

cons

umab

les

susp

ects

fo

r A

AFB

m

icro

scop

y,

cons

umab

les

for

Gen

e X

pert

Proc

ure

Labo

rato

ry c

onsu

mab

les

susp

ects

fo

r A

AFB

m

icro

scop

y,

cons

umab

les

for

Gen

e X

pert

Prot

ecti

ve g

ear

(ass

orte

d)

Prot

ecti

ve g

ear

(ass

orte

d)

Prot

ecti

ve g

ear

(ass

orte

d)

Prot

ecti

ve g

ear

(ass

orte

d)

Prot

ecti

ve g

ear

(ass

orte

d)

Ann

ual C

alib

rati

on o

f G

eneX

pert

Ann

ual

Cal

ibra

tion

of

G

eneX

pert

Ann

ual

Cal

ibra

tion

of

G

eneX

pert

Ann

ual

Cal

ibra

tion

of

G

eneX

pert

Ann

ual C

alib

rati

on o

f G

eneX

pert

Proc

ure

LED

mic

rosc

ope

for

high

vo

lum

e ho

spit

als,

M

icro

scop

es

CX

31

Oly

mp,

G

ene

Xpe

rt

Equi

pmen

t

Proc

ure

LED

m

icro

scop

e fo

r hi

gh

volu

me

hosp

ital

s,

Mic

rosc

opes

C

X31

O

lym

p,

Gen

e X

pert

Equ

ipm

ent

125

Xpe

rtPr

ocur

e LE

D

mic

rosc

ope

for

high

vo

lum

e ho

spit

als,

M

icro

scop

es

CX

31

Oly

mp,

G

ene

Xpe

rt E

quip

men

t

340

LED

m

icro

scop

esPr

ocur

e LE

D

mic

rosc

ope

for

high

vo

lum

e ho

spit

als,

M

icro

scop

es

CX

31

Oly

mp,

G

ene

Xpe

rt E

quip

men

t

125

Xpe

rtPr

ocur

e LE

D m

icro

scop

e fo

r hi

gh v

olum

e ho

spit

als,

Mic

rosc

opes

CX

31 O

lym

p, G

ene

Xpe

rt E

quip

men

t

Cos

t fo

r fr

eigh

t an

d in

sura

nce

for

LED

and

ligh

t m

icro

scop

es

Cos

t fo

r fr

eigh

t an

d in

sura

nce

for

LED

and

ligh

t m

icro

scop

es

11%

of

p

rocu

rem

en

t co

sts

Cos

t fo

r fr

eigh

t an

d in

sura

nce

for

LED

and

ligh

t m

icro

scop

es

11%

of

p

roc

ure

me

nt

cost

s

Cos

t for

frei

ght a

nd in

sura

nce

for L

ED a

nd li

ght m

icro

scop

es

11%

of

p

roc

ure

me

nt

cost

s

Cos

t fo

r fr

eigh

t an

d in

sura

nce

for

LED

and

lig

ht m

icro

scop

es

11%

of

pr

ocur

emen

t co

sts

Aut

omat

ic w

ater

dis

tile

r, ca

paci

ty

4-12

lts

per

hr, d

isti

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4.3.8. Enhance evidence-based program monitoring and evaluation1. Situational Analysis

A robust and responsive surveillance, monitoring and evaluation (M&E) system is important for ensuring quality TB, leprosy and lung disease control. The NLTD-Program is implementing an electronic patient-based surveillance system it developed, called “TIBU”1. The first of its kind in Africa, “TIBU” is the Swahili word for “treat”, and is an acronym for Treatment Information from Basic Program. The aim of TIBU is to maintain electronic records of all patients, enabling real-time evaluation of programme performance at any level. TIBU is decentralized to the sub-county level, and data can be aggregated up to the national level. TIBU has yielded a robust database with comprehensive patient parameters. It has various functions for patient management and payment to patients and field officers.

The patient management system does the following:

1. Online data capture of patient-based information2. Data transfer in real time to central program3. Ability to generate real time reports at any level4. Identification of duplicate patient entries.

The payment module does the following:

1. Funds transfer to NTLD Program staff to reimburse them for supportive supervision and routine surveillance activities 2. Funds transfer to MDR-TB patients for financial support, using MPESA3. Improves governance and accountability through utilization of mobile money transfer.

Information generated from this system is further utilized for operational research at various levels of health care delivery. The NTLD Program has further made efforts to ensure that the quality of the data generated by this system is maintained through regular supportive supervision, data quality assessments (DQAs), data validation meetings and capacity building of health care workers. Primary data capture tools have been in use at the health facility level of care provision.

A national M&E plan was drafted in 2014, containing details for monitoring all core DOTS, TB/HIV and PMDT activities in the Kenyan context. The logical framework for the M&E system is shown below.

_______________________________________________________________________________________________________________________________1 TIBU was developed through a partnership with various organizations. Partners include the Government of Kenya, which provides policy guidance and is the main implementer of the system. Safaricom provides communication and data storage services with cloud hosting. The other two partners are TangazoLetu, which provides payment solutions for the system, and Iridium Interactive, which supports the patient management module. The USG through USAID provided funding for development and operationalization of the system.

Figure 29: M&E Logical Framework

4.3.8. Monitoring and Evaluation

106

4.3.

8. M

onit

orin

g an

d Ev

alua

tion

2. Strategic Direction(s) for 2015-2018

For the period of this NSP, the NTLD Program will focus on maintaining data quality and further decentralizing data management knowledge and skills to county and sub-county level health care workers to promote ownership and data use.

Based on successful early experience with the current surveillance system, the NLTD-Program can now refine the system to make it more integrated and to better serve all of the needs of the programme and other stakeholders. The platform can be extended to host data of other communicable diseases. Capacity building will be prioritized to enable the use of programmatic data and operational research for decision-making.

3. Proposed Approaches

Continuously improve monitoring and evaluation tools and capacities at all levels

1. Develop an M&E training curriculum that reflects the use of TIBU; operationalize a cascade of training on M&E, data management and data use for decision-making

2. Enhance supervision and on-the-job mentorship at county and facility levels to improve the quality of recording and reporting. Revise and promote the use of the supervision checklist to provide immediate feedback.

3. Ensure availability and usage of all standardized and up-to-date revised recording and reporting tools at all levels. 4. Revise M&E policies and components in the National Guidelines 5. Support the roll-out of ICD 10.

Strengthen TIBU and its integration with other surveillance platforms

1. Expand TIBU to:a. Link with the Laboratory Management Information System (LIMS), the Community-based Health Information System (CBHIS) through DHIS-2, and the overall Health Management Information System (HMIS).

b. Introduce new TIBU modules recommended by the mid-term review to support the capture of activities related to: PMDT, prevention and intensified case finding, collaborative TB/HIV, presumptive TB, contact tracing, community TB, supervision and others areas.

c. Create and implement a financial reporting tool within TIBU to monitor sub-sector (TB) finance expenditure.

d. Explore TIBU as an M&E platform for other communicable disease control programs.

2. Enhance the automated analytic functions of TIBU to aid in the utilization of the data. The NTLD Program plans to create a dashboard of key performance indicators at the various levels of TB control services (county, sub-county and service delivery points). The dashboard will also have warning signs when immediate action needs to be taken.

3. Improve the vital registration system to better capture TB deaths.

4. Support the mainstreaming of SHA-2011.

Improve TB financial reporting and quantification

Develop and pilot a financial reporting tool linked to the TB sub-sector health accounts monitoring.

Improve mortality statistics

Build capacity for ICD-10 classification and reporting.

Improve the quality and systematic use of strategic information

1. Conduct routine and systematic data quality assessments (DQAs) at county and national level to improve data completeness, consistency and accuracy

2. Conduct data validation meetings and monthly data review meetings at sub-county level3. Guide counties to develop their M&E plan as part of defining their health strategy, setting county specific targets

for TB, leprosy and lung health4. Maintain a functional M&E technical working group (TWG) at national level and support the formation of an M&E

TWG in each county. 5. Strengthen the infrastructure across the NTLD Program network for data use

107

4.3.8. Monitoring and Evaluation

6. Evaluate and communicate data use successes

Ensure availability of a supporting infrastructure

1. Establish a functional Data Management Program at central level to oversee all aspects of data management2. Provide tablets and computers, where needed, for data capture and management3. Improve the current email hosting to Google Cloud from group wise, to facilitate easy internet access and minimize

the occurrence of disconnections.

Promote impact assessment and prioritize research, including operational research, which will address programme challenges

To continue to build the evidence-base for TB, leprosy and lung disease control, capacity to conduct studies, including operational research (OR) will continue to be built among all TB stakeholders.

There will be a renewed focus on the application of evidence generated from studies to improve outcomes and show the impact of new approaches and ongoing activities. Staff will be encouraged to contribute to the regional and global evidence-base by presenting their findings at national and international conferences, and publish manuscripts in peer reviewed journals. To ensure research is focused and addresses the key challenges, a collaborative OR agenda will be developed with all key stakeholders. A preliminary list of operational research priorities is highlighted below (See Table 14).

Enhancing operational research will require the NTLD Program to:

1. Revamp the research task force at the national level and establish similar forums at county level. The research task force will be supported to mentor counties

2. Identify OR trainees who are well positioned to conduct and apply research; build for impact assessments and operational research; and enable them to serve as future trainers and mentors

3. Convene biannual forums to share research findings at the county level, including national lung health conference(s)4. Develop and implement a prioritized operational research agenda within the next three-year plan and continue

building operational research capacity (learning while doing/mentorship) throughout the health system.

108

4.3.

8. M

onit

orin

g an

d Ev

alua

tion

Operational Research Priorities

National, Ongoing

1. Prevalence Survey (2015-2016)2. DRS (2015)3. Mortality Study4. Pediatric TB HIV study5. Delay in diagnosis study (to be completed, ongoing)6. Inventory Studies

National

1. KAP (to be comprehensive – legislators, patients, HCWs, media, community)2. The impact of Xpert MTB on diagnosis of TB (as per the national protocol) 3. Outcomes of ICF and IPT implementation in routine clinical settings in Kenya4. Prevalence of pulmonary aspergilosis in PTB patients5. Burden of Lung Disease (BOLD) study nationally

Counties

1. In counties with treatment success <80%, assess factors2. Assess barriers to treatment adherence3. Assess models for improving case holding by community and family-based DOTS4. In counties where decline in case notification is >5%/year, assess if true decline and assess factors5. Routinely do exit interviews among the patients to capture information source of patient prior to

treatment as a quality of care assessment

Desktop Reviews

1. Ascertain the coverage of TB, Leprosy and LD in the mass media2. Longitudinal data analysis of smear microscopy EQA to determine quality improvement trends and

recurrent gaps3. Longitudinal data analysis on Culture and DST services to determine trends4. Outcome of MDR-TB in children and child MDR-TB contacts5. Documentation of best practices and timely application of best Social Protection Practices6. Impact of food support on TB treatment outcomes7. Determination of various factors associated with the different treatment outcomes8. Analysis of mortality statistics

Enhance research literacy among CHWs to enable them understand the results and the importance of research

Table 14: Operational Research Priorities

109

4.3.8. Monitoring and Evaluation

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t re

gist

ers

to 4

7 co

unti

es

Dis

trib

ute

cont

act

reg

iste

rsn/

aD

istr

ibut

e 4,

000

copi

es

of

cont

act

regi

ster

s up

to t

o co

unty

leve

ln/

aD

istr

ibut

e 4,

000

copi

es

of

cont

act

regi

ster

s up

to t

o co

unty

leve

l

Prop

orti

on

of

faci

litie

s us

ing

the

inte

grat

ed

tool

to

re

port

th

roug

h D

HIS

Inte

rgra

te

case

find

ing

and

coho

rt

repo

rtin

g to

ol

into

M

OH

71

1 fa

cilit

y re

port

ing

tool

Hol

d a

2 da

y re

trea

t to

int

ergr

ate

the

tool

s0

n/a

2%H

old

a 2

day

mee

ting

to

revi

ew t

he

inte

grat

ed t

ool

80%

n/a

100%

Pret

esti

ng o

f th

e in

terg

rate

d to

ols

n/a

Pret

est

the

tool

in t

he 5

mod

el c

oun-

ties

tar

gett

ing

all t

he c

ount

y an

d su

b co

unty

hos

pita

ls

n/a

n/a

Prin

ting

of

the

tool

Prin

t 50

cop

ies

for

pret

est

Prin

t 4,

000

copi

es f

or d

isse

min

atio

nn/

aPr

int

4,00

0 co

pies

for

dis

sem

inat

ion

Dis

sem

inat

e in

terg

rate

d to

ols

n/a

n/a

Hol

d a

1 da

y m

eeti

ng t

o di

ssem

inat

e in

tegr

ated

too

l in

47 c

ount

ies

n/a

Dis

trib

ute

inte

rgra

ted

tool

sn/

an/

aU

se c

ouri

er t

o di

stri

bute

4,0

00

copi

es o

f in

tegr

ated

too

l up

to

coun

ty le

vel

n/a

4.3.

8. M

onit

orin

g an

d Ev

alua

tion

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on o

f TB

dia

gnos

tic

labs

pr

ovid

ed w

ith

all

the

rele

vant

to

ols

Revi

se

labo

rato

ry

data

co

llect

ion

and

repo

rtin

g to

ols

Hol

d a

5 da

y m

eeti

ng t

o re

vise

eac

h of

the

12

type

s of

la

b re

cord

ing

and

repo

rtin

g to

ols

100%

n/a

100%

Revi

se, p

rint

and

dis

sem

inat

e ea

ch o

f th

e 12

typ

es o

f l

ab d

ata

colle

ctio

n to

ols

100%

n/a

100%

Prop

orti

on o

f TB

dia

gnos

tic

labs

pr

ovid

ed w

ith

all

the

rele

vant

to

ols

Prin

t A

FB m

icro

scop

y, X

pert

, cu

ltur

e/D

ST

requ

est

form

s .

Lab

regi

ster

s (A

FB,

Cul

ture

, X

pert

), EQ

A f

orm

s

3,60

0 bo

okle

ts f

or A

FB o

f 10

0 pa

ges,

4,00

0 bo

okle

ts o

f 50

dup

licat

e le

afs

for

cult

ure,

2,

500

AFB

reg

iste

rs,

200

Xpe

rt

regi

ster

s of

10

0 pa

ges,

20

,000

bo

okle

ts

of

GX

pert

re

ques

t fo

rms

of 5

0 pa

ges,

1,80

0 bo

okle

ts o

f EQ

A S

ampl

ing

form

s of

50

leaf

s,

1,80

0 bo

okle

ts o

f EQ

A a

naly

sis

form

s of

50

leaf

s,

500

book

lets

of E

QA

wor

kloa

d su

mm

ary

of 5

0 le

afs

in t

ripl

icat

e,

250

book

lets

of

EQA

dis

cord

ant

form

s of

50

leaf

s,1,

800

book

lets

of E

QA

che

cklis

t 50

leaf

s in

tri

plic

ate,

1,80

0 A

FB Jo

b ai

ds

3,60

0 bo

okle

ts f

or A

FB o

f 10

0 pa

ges,

4,00

0 bo

okle

ts o

f 50

dup

licat

e l

eafs

fo

r cu

ltur

e,

2,50

0 A

FB r

egis

ters

, 20

0 X

pert

re

gist

ers

of

100

page

s,

20,0

00

book

lets

of

G

Xpe

rt

requ

est

form

s of

50

page

s,1,

800

book

lets

of

EQA

Sam

plin

g fo

rms

of 5

0 le

afs,

1,

800

book

lets

of

EQA

ana

lysi

s fo

rms

of 5

0 le

afs,

50

0 bo

okle

ts

of

EQA

w

orkl

oad

sum

mar

y of

50

leaf

s in

tri

plic

ate,

25

0 bo

okle

ts o

f EQ

A d

isco

rdan

t fo

rms

of 5

0 le

afs,

1,80

0 bo

okle

tsof

EQ

A

chec

klis

t 50

le

afs

in t

ripl

icat

e,1,

800

AFB

Job

aids

3,60

0 bo

okle

ts fo

r AFB

of 1

00 p

ages

,4,

000

book

lets

of

50 d

uplic

ate

leaf

s fo

r cu

ltur

e,

2,50

0 A

FB r

egis

ters

, 20

0 X

pert

reg

iste

rs o

f 10

0 pa

ges,

20

,000

boo

klet

s of

GX

pert

req

uest

fo

rms

of 5

0 pa

ges,

1,80

0 bo

okle

ts

of

EQA

Sa

mpl

ing

form

s of

50

leaf

s,

1,80

0 bo

okle

ts

of

EQA

an

alys

is

form

s of

50

leaf

s,

500

book

lets

of

EQ

A

wor

kloa

d su

mm

ary

of 5

0 le

afs

in t

ripl

icat

e,

250

book

lets

of

EQ

A

disc

orda

nt

form

s of

50

leaf

s,1,

800

book

lets

of E

QA

che

cklis

t 50

le

afs

in t

ripl

icat

e,1,

800

AFB

Job

aids

3,60

0 bo

okle

ts f

or A

FB o

f 10

0 pa

ges,

4,00

0 bo

okle

ts o

f 50

dup

licat

e l

eafs

fo

r cu

ltur

e,

2,50

0 A

FB r

egis

ters

, 20

0 X

pert

re

gist

ers

of

100

page

s,

20,0

00

book

lets

of

G

Xpe

rt

requ

est

form

s of

50

page

s,1,

800

book

lets

of

EQA

Sam

plin

g fo

rms

of 5

0 le

afs,

1,

800

book

lets

of

EQA

ana

lysi

s fo

rms

of 5

0 le

afs,

50

0 bo

okle

ts

of

EQA

w

orkl

oad

sum

mar

y of

50

leaf

s in

tri

plic

ate,

25

0 bo

okle

ts o

f EQ

A d

isco

rdan

t fo

rms

of 5

0 le

afs,

1,80

0 bo

okle

tsof

EQ

A c

heck

list

50 le

afs

in t

ripl

icat

e,1,

800

AFB

Job

aids

Dis

sem

inat

e la

b re

cord

ing

and

repo

rtin

g to

oln/

aH

old

1 m

eeti

ng

to

diss

emin

ate

lab

reco

rdin

g an

d re

port

ing

tool

sn/

aH

old

1 m

eeti

ng

to

diss

emin

ate

lab

reco

rdin

g an

d re

port

ing

tool

s

Dis

trib

ute

lab

reco

rdin

g an

d re

port

ing

tool

sn/

aU

se c

ouri

er t

o di

stri

bute

var

ious

lab

re

cord

ing

and

repo

rtin

g to

ols

upto

co

unty

leve

l

n/a

Use

co

urie

r to

di

stri

bute

va

riou

s la

b re

cord

ing

and

repo

rtin

g to

ols

upto

co

unty

leve

l

Prop

orti

on

of

sub-

coun

ties

re

port

ing

100%

of

th

eir

faci

litie

s us

ing

pati

ent

card

s

Revi

se T

B pa

tien

t re

cord

car

dH

old

a TW

G to

revi

ew th

e pa

tien

t rec

ord

card

an

inco

pora

te n

ew d

efin

itio

ns10

0%n/

a10

0%n/

a10

0%n/

a10

0%

Prin

t pa

tien

t TB

rec

ord

card

Prin

t 10

0,00

0 pa

tien

t re

cord

car

ds-

Prin

t 10

0,00

0 pa

tien

t re

cord

car

dsn/

a

Dis

trib

ute

pati

ent

TB

reco

rd

card

n/a

Use

co

urie

r to

di

stri

bute

ca

rds

up

coun

ty le

vel

n/a

Use

co

urie

r to

di

stri

bute

ca

rds

up

coun

ty le

vel

Prop

orti

on

of

sub-

coun

ties

re

port

ing

100%

of

th

eir

faci

litie

s us

ing

lung

di

seas

es

reco

rdin

g to

ols

Revi

se l

ung

dise

ase

reco

rdin

g an

d re

port

ing

tool

sn/

a0%

Hol

d 5

day

mee

ting

to

re

vise

lu

ng

dise

ase

reco

drin

g an

d re

port

ing

tool

s50

%n/

a10

0%n/

a10

0%

Prin

t 4,

000

copi

es

of

lung

di

seas

e re

cord

ing

and

repo

rtin

g to

ols

n/a

Prin

t 4

,000

co

pies

of

lung

dis

ease

re

cord

ing

and

repo

rtin

g to

ols

n/a

n/a

Dis

sem

inat

e lu

ng

dise

ase

reco

rdin

g an

d re

port

ing

tool

sn/

aH

old

1 m

eeti

ng t

arge

ting

47

coun

ties

to

dis

sem

inat

e lu

ng d

isea

se r

ecor

ding

an

d re

port

ing

tool

s

n/a

n/a

Dis

trib

ute

lung

di

seas

e re

cord

ing

and

repo

rtin

g to

ols

n/a

Use

cou

rier

to

dist

ribu

te 4

,000

cop

ies

of lu

ng d

isea

se t

ools

upt

o co

unty

leve

l n/

an/

a

4.3.8. Monitoring and Evaluation

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on o

f TB

dia

gnos

tic

labs

pr

ovid

ed w

ith

all

the

rele

vant

to

ols

Revi

se

labo

rato

ry

data

co

llect

ion

and

repo

rtin

g to

ols

Hol

d a

5 da

y m

eeti

ng t

o re

vise

eac

h of

the

12

type

s of

la

b re

cord

ing

and

repo

rtin

g to

ols

100%

n/a

100%

Revi

se, p

rint

and

dis

sem

inat

e ea

ch o

f th

e 12

typ

es o

f l

ab d

ata

colle

ctio

n to

ols

100%

n/a

100%

Prop

orti

on o

f TB

dia

gnos

tic

labs

pr

ovid

ed w

ith

all

the

rele

vant

to

ols

Prin

t A

FB m

icro

scop

y, X

pert

, cu

ltur

e/D

ST

requ

est

form

s .

Lab

regi

ster

s (A

FB,

Cul

ture

, X

pert

), EQ

A f

orm

s

3,60

0 bo

okle

ts f

or A

FB o

f 10

0 pa

ges,

4,00

0 bo

okle

ts o

f 50

dup

licat

e le

afs

for

cult

ure,

2,

500

AFB

reg

iste

rs,

200

Xpe

rt

regi

ster

s of

10

0 pa

ges,

20

,000

bo

okle

ts

of

GX

pert

re

ques

t fo

rms

of 5

0 pa

ges,

1,80

0 bo

okle

ts o

f EQ

A S

ampl

ing

form

s of

50

leaf

s,

1,80

0 bo

okle

ts o

f EQ

A a

naly

sis

form

s of

50

leaf

s,

500

book

lets

of E

QA

wor

kloa

d su

mm

ary

of 5

0 le

afs

in t

ripl

icat

e,

250

book

lets

of

EQA

dis

cord

ant

form

s of

50

leaf

s,1,

800

book

lets

of E

QA

che

cklis

t 50

leaf

s in

tri

plic

ate,

1,80

0 A

FB Jo

b ai

ds

3,60

0 bo

okle

ts f

or A

FB o

f 10

0 pa

ges,

4,00

0 bo

okle

ts o

f 50

dup

licat

e l

eafs

fo

r cu

ltur

e,

2,50

0 A

FB r

egis

ters

, 20

0 X

pert

re

gist

ers

of

100

page

s,

20,0

00

book

lets

of

G

Xpe

rt

requ

est

form

s of

50

page

s,1,

800

book

lets

of

EQA

Sam

plin

g fo

rms

of 5

0 le

afs,

1,

800

book

lets

of

EQA

ana

lysi

s fo

rms

of 5

0 le

afs,

50

0 bo

okle

ts

of

EQA

w

orkl

oad

sum

mar

y of

50

leaf

s in

tri

plic

ate,

25

0 bo

okle

ts o

f EQ

A d

isco

rdan

t fo

rms

of 5

0 le

afs,

1,80

0 bo

okle

tsof

EQ

A

chec

klis

t 50

le

afs

in t

ripl

icat

e,1,

800

AFB

Job

aids

3,60

0 bo

okle

ts fo

r AFB

of 1

00 p

ages

,4,

000

book

lets

of

50 d

uplic

ate

leaf

s fo

r cu

ltur

e,

2,50

0 A

FB r

egis

ters

, 20

0 X

pert

reg

iste

rs o

f 10

0 pa

ges,

20

,000

boo

klet

s of

GX

pert

req

uest

fo

rms

of 5

0 pa

ges,

1,80

0 bo

okle

ts

of

EQA

Sa

mpl

ing

form

s of

50

leaf

s,

1,80

0 bo

okle

ts

of

EQA

an

alys

is

form

s of

50

leaf

s,

500

book

lets

of

EQ

A

wor

kloa

d su

mm

ary

of 5

0 le

afs

in t

ripl

icat

e,

250

book

lets

of

EQ

A

disc

orda

nt

form

s of

50

leaf

s,1,

800

book

lets

of E

QA

che

cklis

t 50

le

afs

in t

ripl

icat

e,1,

800

AFB

Job

aids

3,60

0 bo

okle

ts f

or A

FB o

f 10

0 pa

ges,

4,00

0 bo

okle

ts o

f 50

dup

licat

e l

eafs

fo

r cu

ltur

e,

2,50

0 A

FB r

egis

ters

, 20

0 X

pert

re

gist

ers

of

100

page

s,

20,0

00

book

lets

of

G

Xpe

rt

requ

est

form

s of

50

page

s,1,

800

book

lets

of

EQA

Sam

plin

g fo

rms

of 5

0 le

afs,

1,

800

book

lets

of

EQA

ana

lysi

s fo

rms

of 5

0 le

afs,

50

0 bo

okle

ts

of

EQA

w

orkl

oad

sum

mar

y of

50

leaf

s in

tri

plic

ate,

25

0 bo

okle

ts o

f EQ

A d

isco

rdan

t fo

rms

of 5

0 le

afs,

1,80

0 bo

okle

tsof

EQ

A c

heck

list

50 le

afs

in t

ripl

icat

e,1,

800

AFB

Job

aids

Dis

sem

inat

e la

b re

cord

ing

and

repo

rtin

g to

oln/

aH

old

1 m

eeti

ng

to

diss

emin

ate

lab

reco

rdin

g an

d re

port

ing

tool

sn/

aH

old

1 m

eeti

ng

to

diss

emin

ate

lab

reco

rdin

g an

d re

port

ing

tool

s

Dis

trib

ute

lab

reco

rdin

g an

d re

port

ing

tool

sn/

aU

se c

ouri

er t

o di

stri

bute

var

ious

lab

re

cord

ing

and

repo

rtin

g to

ols

upto

co

unty

leve

l

n/a

Use

co

urie

r to

di

stri

bute

va

riou

s la

b re

cord

ing

and

repo

rtin

g to

ols

upto

co

unty

leve

l

Prop

orti

on

of

sub-

coun

ties

re

port

ing

100%

of

th

eir

faci

litie

s us

ing

pati

ent

card

s

Revi

se T

B pa

tien

t re

cord

car

dH

old

a TW

G to

revi

ew th

e pa

tien

t rec

ord

card

an

inco

pora

te n

ew d

efin

itio

ns10

0%n/

a10

0%n/

a10

0%n/

a10

0%

Prin

t pa

tien

t TB

rec

ord

card

Prin

t 10

0,00

0 pa

tien

t re

cord

car

ds-

Prin

t 10

0,00

0 pa

tien

t re

cord

car

dsn/

a

Dis

trib

ute

pati

ent

TB

reco

rd

card

n/a

Use

co

urie

r to

di

stri

bute

ca

rds

up

coun

ty le

vel

n/a

Use

co

urie

r to

di

stri

bute

ca

rds

up

coun

ty le

vel

Prop

orti

on

of

sub-

coun

ties

re

port

ing

100%

of

th

eir

faci

litie

s us

ing

lung

di

seas

es

reco

rdin

g to

ols

Revi

se l

ung

dise

ase

reco

rdin

g an

d re

port

ing

tool

sn/

a0%

Hol

d 5

day

mee

ting

to

re

vise

lu

ng

dise

ase

reco

drin

g an

d re

port

ing

tool

s50

%n/

a10

0%n/

a10

0%

Prin

t 4,

000

copi

es

of

lung

di

seas

e re

cord

ing

and

repo

rtin

g to

ols

n/a

Prin

t 4

,000

co

pies

of

lung

dis

ease

re

cord

ing

and

repo

rtin

g to

ols

n/a

n/a

Dis

sem

inat

e lu

ng

dise

ase

reco

rdin

g an

d re

port

ing

tool

sn/

aH

old

1 m

eeti

ng t

arge

ting

47

coun

ties

to

dis

sem

inat

e lu

ng d

isea

se r

ecor

ding

an

d re

port

ing

tool

s

n/a

n/a

Dis

trib

ute

lung

di

seas

e re

cord

ing

and

repo

rtin

g to

ols

n/a

Use

cou

rier

to

dist

ribu

te 4

,000

cop

ies

of lu

ng d

isea

se t

ools

upt

o co

unty

leve

l n/

an/

a

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on

of

regi

ster

ed

CU

's

repo

rtin

g co

mm

unit

y TB

ac

tivi

ties

thr

ough

DH

IS/T

IBU

Dev

elop

/rev

ise

com

mun

ity

reco

rdin

g an

d re

port

ing

tool

sH

old

5 da

y m

etin

g to

re

vise

/dev

elop

co

mm

unit

y re

cord

ing

and

repo

rtin

g to

ols

0%n/

a50

%n/

a10

0%n/

a10

0%

Prin

t co

mm

unit

y re

cord

ing

and

repo

rtin

g to

ols

Prin

t 10

,000

cop

ies

of c

omm

unit

y to

ols

n/a

n/a

n/a

Dis

sem

inat

e co

mm

unit

y to

ols

Hol

d 1

day

diss

emin

atio

n m

eeti

ng

targ

etin

g C

TLC

and

com

mun

ity

prog

ram

co

ordi

nato

rs t

o di

ssem

inat

e co

mm

unit

y to

ols

n/a

n/a

n/a

Dis

trib

ute

com

mun

ity

tool

sn/

aU

se c

ouri

er t

o di

ssem

inat

e to

ols

upto

co

unty

leve

ln/

an/

a

Prop

orti

on o

f pr

inte

d to

ols

wit

h SO

Ps in

tegr

ated

Dev

elop

SO

Ps o

n us

e of

dat

a co

llect

ion

and

reco

rdin

g to

ols

deve

lope

d/re

vise

d

Dev

elop

SO

Ps o

n us

e of

dat

a co

llect

ion

and

reco

rdin

g to

ols

deve

lope

d/re

vise

d50

%Pr

int

and

diss

emin

ate

data

col

lect

ion

and

reco

rdin

g to

ols

wit

h SO

Ps

inco

rpor

ated

100%

Prin

t an

d di

ssem

inat

e da

ta c

olle

c -ti

on a

nd r

ecor

ding

too

ls w

ith

SOPs

in

corp

orat

ed

100%

Prin

t an

d di

ssem

inat

e da

ta c

olle

ctio

n an

d re

cord

ing

tool

s w

ith

SOPs

inco

r-po

rate

d

100%

Stra

tegi

c A

ppro

ach

2: S

tren

gthe

n TI

BU a

nd it

s in

tegr

atio

n w

ith

othe

r su

rvei

llanc

e pl

atfo

rms

TIBU

Ph

ase

III

com

plet

ed

and

sign

ed o

ffIm

prov

e TI

BU to

acc

omm

odat

e ne

w

func

tion

s an

d lin

kage

w

ith

othe

r sy

stem

s

Enga

ge

TIBU

Ph

ase

III

deve

lope

rs

to

resc

ope

and

star

t ex

pans

ion

of

the

syst

em t

o in

clud

e co

mm

unit

y, T

B/H

IV,

linka

ge

wit

h D

HIS

, G

eneX

pert

A

lert

sy

stem

and

LM

IS a

nd o

ther

fel

t ne

eds

n/a

1n/

an/

a

Hol

d 3

day

retr

eat

for

resc

opin

g TI

BU

Phas

e III

n/a

n/a

n/a

Build

con

sens

us o

n in

tegr

atio

n of

TIB

U w

ith

othe

r sy

stem

sC

ondu

ct 3

day

s st

akeh

olde

rs m

eeti

ng t

o bu

ild c

onse

nsus

on

inte

grat

ion

of T

IBU

w

ith

othe

r in

form

atio

n m

anag

emen

t sy

stem

s

n/a

n/a

n/a

Hol

d w

eekl

y op

erat

ions

TW

G

mee

ting

s (1

5 pa

x)Su

ppor

t op

erat

ions

TW

G t

o ho

ld w

eekl

y m

eeti

ngs

to

over

see

deve

lopm

ent

of

TIBU

Pha

se II

I

n/a

n/a

n/a

Hol

d m

onth

ly

polic

y TW

G

mee

ting

sSu

ppor

t po

licy

team

to

hold

mon

thly

m

eeti

ngs

to

give

di

rect

ion

on

TIBU

Ph

ase

III d

evel

opm

ent

n/a

n/a

n/a

Pilo

t TI

BU P

hase

III

Supp

ort 5

cou

ntie

s to

pilo

t TIB

U P

hase

III

and

give

fee

dbac

kn/

an/

an/

a

Roll

out

TIBU

Pha

se II

I Tr

ain

TIBU

end

use

rs f

or 3

day

s to

sta

rt

usin

g TI

BU P

hase

III

n/a

n/a

n/a

hold

a

2 da

y st

akeh

olde

rs

mee

ting

to

re

view

us

e an

d im

pact

of

TIBU

n/a

n/a

Supp

ort

a 3

day

stak

ehol

ders

m

eeti

ng to

dis

cuss

impa

ct o

f TIB

U to

in

clud

e M

OH

off

icia

ls,

NG

O,

dono

rs

and

deve

lope

rs

n/a

Con

duct

TI

BU

refr

eshe

r tr

aini

ng

n/a

n/a

Supp

ort a

2 d

ay re

fres

her t

rain

ing

for

TIBU

end

use

rs t

o ad

dres

s em

ergi

ng

issu

es

n/a

Prov

ide

cont

inuo

us

tech

nica

l su

ppor

t on

TIB

UD

evel

op t

ools

for

use

at

TIBU

hel

p de

sk

to

capt

ure

fiel

d is

sues

re

port

ed

and

resp

onse

pro

vide

d

Supp

ort

2 IT

sta

ff t

o m

an T

IBU

he

lp

desk

n/a

n/a

4.3.

8. M

onit

orin

g an

d Ev

alua

tion

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

3: Im

prov

e TB

fin

anci

al r

epor

ting

and

qua

ntif

icat

ion

of n

eeds

Prop

orti

on o

f cou

ntie

s re

port

ing

TB f

inan

cial

dat

a an

nual

lyD

evel

op a

fin

anci

al r

epor

ting

to

olC

ondu

ct d

esk

revi

ew a

nd d

evel

opm

ent

of t

he N

TLD

Pro

gram

fin

anci

al r

epor

ting

to

ol

0%D

isse

min

ate

the

fina

ncia

l re

port

ing

tool

, inc

ludi

ng t

rain

ing

50%

Dis

sem

inat

e th

e fi

nanc

ial

repo

rtin

g to

ol, i

nclu

ding

tra

inin

g80

%D

isse

min

ate

the

fina

ncia

l re

port

ing

tool

, inc

ludi

ng t

rain

ing

100%

Mon

itor

ing

of s

ub-s

ecto

r (T

B)

fina

nce

expe

ndit

ure

Ana

lysi

s of

TB

su

b se

ctor

fi

nanc

ial

expe

ndit

ures

A

naly

sis

of

TB

sub

sect

or

fina

ncia

l ex

pend

itur

es

Ana

lysi

s of

TB

sub

sect

or f

inan

cial

ex

pend

itur

es

Ana

lysi

s of

TB

su

b se

ctor

fi

nanc

ial

expe

ndit

ures

Supp

ort

the

mai

nstr

eam

ing

of

SHA

-201

1 Su

ppor

t th

e pa

rtic

ipat

ion

of K

ey M

&E

staf

f in

the

pro

gram

to

part

icip

ate

in t

he

SHA

-pro

cess

for

Ken

ya

Supp

ort

the

part

icip

atio

n of

Key

M&

E st

aff

in t

he p

rogr

am t

o pa

rtic

ipat

e in

th

e SH

A-p

roce

ss f

or K

enya

Supp

ort t

he p

arti

cipa

tion

of K

ey M

&E

staf

f in

the

pro

gram

to

part

icip

ate

in

the

SHA

-pro

cess

for

Ken

ya

Supp

ort

the

part

icip

atio

n of

Key

M&

E st

aff

in t

he p

rogr

am t

o pa

rtic

ipat

e in

th

e SH

A-p

roce

ss f

or K

enya

Stra

tegi

c A

ppro

ach

4: Im

prov

e TB

, lep

rosy

and

lung

dis

ease

mor

talit

y st

atis

tics

Prop

orti

on o

f fa

cilit

ies

repo

rtin

g m

orta

lity

stat

isti

cs u

sing

ICD

-10

Trai

n 2,

400

HC

W

and

regi

stra

tion

age

nts

on t

he u

se

of v

erba

l aut

opsy

Con

duct

tr

aini

ng

600

Hea

lth

care

w

orke

rs

and

regi

stra

tion

ag

ents

on

V

erba

l aut

opsy

20%

Trai

ning

of 6

00 h

ealt

h ca

re w

orke

rs a

nd

regi

stra

tion

age

nts

on v

erba

l aut

opsy

50%

Trai

ning

of

600

Hea

lth

care

wor

kers

an

d re

gist

rati

on

agen

ts

on

Ver

bal

auto

psy

85%

Trai

ning

of 6

00 H

ealt

h ca

re w

orke

rs a

nd

regi

stra

tion

age

nts

on V

erba

l aut

opsy

>85

%

Trai

n 4,

800

heal

th

care

w

orke

rs

on

codi

ng/

cert

ific

atio

n

Trai

ning

of

1,20

0 H

ealt

h ca

re w

orke

rs

on IC

D-1

0 tr

aini

ngTr

aini

ng o

f 1,

200

heal

th c

are

wor

kers

on

ICD

-10

trai

ning

Trai

ning

of

1,

200

Hea

lth

care

w

orke

rs o

n IC

D-1

0 tr

aini

ngTr

aini

ng o

f 1,

200

Hea

lth

care

wor

kers

on

ICD

-10

trai

ning

Car

ry o

ut a

naly

sis

of m

orta

lity

stat

isti

cs

toge

ther

w

ith

CRD

an

d K

NBS

Hol

d 2

wor

ksho

ps t

o an

alyz

e m

orta

lity

stat

isti

cs a

nd p

rodu

ce a

rep

ort

Hol

d 2

wor

ksho

ps t

o an

alyz

e m

orta

lity

stat

isti

cs a

nd p

rodu

ce a

rep

ort

Hol

d 2

wor

ksho

ps

to

anal

yze

mor

talit

y st

atis

tics

an

d pr

oduc

e a

repo

rt

Hol

d 2

wor

ksho

ps t

o an

alyz

e m

orta

lity

stat

isti

cs a

nd p

rodu

ce a

rep

ort

Stra

tegi

c A

ppro

ach

5: Im

prov

e th

e qu

alit

y an

d sy

stem

atic

use

of

stra

tegi

c in

form

atio

n

Prop

orti

on o

f fac

iliti

es a

chie

ving

se

t da

ta q

ualit

y st

anda

rds

Con

duct

an

nual

ro

utin

e an

d sy

stem

atic

da

ta

qual

ity

asse

ssm

ents

(D

QA

s) a

t co

unty

le

vel

Con

duct

5

day

DQ

A

to

sub

coun

ties

by

cou

nty

team

s88

%C

ondu

ct 5

day

D

QA

to

su

b co

unti

es

by

coun

ty t

eam

s

>88

%C

ondu

ct

5 da

y D

QA

to

su

b co

unti

es

by

co

unty

te

ams

>90

%C

ondu

ct

5 da

y D

QA

to

su

b co

unti

es

by

co

unty

te

ams

>90

%

Prop

orti

on

of

plan

ned

annu

al

DQ

A a

ctiv

itie

s co

nduc

ted

at a

ll le

vels

Con

duct

an

nual

ro

utin

e an

d sy

stem

atic

da

ta

qual

ity

asse

ssm

ent

at

nati

onal

lev

el

to im

prov

e da

ta c

ompl

eten

ess,

co

nsis

tenc

y an

d ac

cura

cy

Con

duct

14

days

DQ

A to

cou

ntie

s by

the

nati

onal

tea

m90

%C

ondu

ct 1

4 da

ys D

QA

to

coun

ties

by

the

nati

onal

tea

m90

%C

ondu

ct 1

4 da

ys D

QA

to

coun

ties

by

the

nati

onal

tea

m90

%C

ondu

ct 1

4 da

ys D

QA

to

coun

ties

by

the

nati

onal

tea

m90

%

Prop

orti

on

of

sub-

coun

ties

co

nduc

ting

m

onth

ly

data

re

view

mee

ting

s

Car

ry o

ut m

onth

ly d

ata

revi

ew

mee

ting

s at

sub

cou

nty

leve

lSu

ppor

t su

bcou

ntie

s to

co

nduc

t m

onth

ly r

evie

w m

eeti

ngs

30%

Supp

ort

subc

ount

ies

to

cond

uct

mon

thly

rev

iew

mee

ting

s66

%Su

ppor

t su

bcou

ntie

s to

co

nduc

t m

onth

ly r

evie

w m

eeti

ngs

90

Dev

elop

/ Re

view

M/E

tra

inin

g cu

rric

ulum

n/a

Revi

ew

th

e M

/E

com

pone

nt

in

the

inte

rgra

ted

curr

icul

umn/

an/

a

Trai

n TO

TS

in

M/E

an

d da

ta

man

agem

ent

n/a

Con

duct

int

ergr

ated

TO

T tr

aini

ng f

or

coun

ty s

taff

n/a

n/a

Prop

orti

on

of

faci

litie

s w

ith

mon

thly

rep

orts

on

TB/M

DR-

TBC

ondu

ct

CM

Es

to

HC

Ws

on

data

man

agem

ent

n/a

Supp

ort

100

sess

ions

of

CM

Es i

n su

b co

unti

es25

%Su

ppor

t 10

0 C

ME

sess

ions

of

in s

ub

coun

ties

50%

Supp

ort

100

sess

ions

of

CM

Es i

n su

b co

unti

es>

80%

4.3.8. Monitoring and Evaluation

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Prop

orti

on

of

coun

ties

w

ith

upda

ted

M&

E pl

ans

Gui

de

coun

ties

to

de

velo

p th

eir

M&

E pl

an

as

part

of

de

fini

ng t

heir

hea

lth

stra

tegy

n/a

n/a

Con

duct

TA

m

issi

ons

to

coun

ties

on

de

velo

pmen

t of

M/E

pla

ns25

%C

ondu

ct T

A m

issi

ons

to c

ount

ies

on

deve

lopm

ent

of M

/E p

lans

50%

Con

duct

TA

m

issi

ons

to

coun

ties

on

de

velo

pmen

t of

M/E

pla

ns10

0%

Supp

ort

use

of

real

ti

me

TIBU

da

ta

to

guid

e pr

ogra

m

acti

viti

es a

t al

l lev

els

Hol

d m

eeti

ng b

y th

e TW

G t

o de

velo

p a

tool

for

gui

ding

on

data

use

Con

duct

5 T

A m

issi

ons

to e

ach

of t

he

mod

el c

ount

ies

Con

duct

5 T

A m

issi

on t

o ea

ch o

f th

e m

odel

cou

ntie

s C

ondu

ct 5

TA

mis

sion

s to

eac

h of

the

m

odel

cou

ntie

s

Prop

orti

on

of

coun

ties

w

ith

func

tion

al T

WG

s on

M&

E an

d O

R

Mai

ntai

n a

func

tion

al

M&

E te

chni

cal

wor

king

gr

oup

(TW

G)

at N

atio

nal

leve

l an

d en

hanc

e th

e fo

rmat

ion

of M

&E

TWG

in e

ach

coun

ty.

n/a

Hol

d qu

arte

rly

TWG

mee

ting

s bo

th a

t co

unty

and

nat

iona

l lev

el10

0%H

old

quar

terl

y TW

G m

eeti

ngs

both

at

cou

nty

and

nati

onal

leve

l10

0%H

old

quar

terl

y TW

G m

eeti

ngs

both

at

coun

ty a

nd n

atio

nal l

evel

100%

Num

ber

and

type

of

da

ta

prod

ucts

pro

duce

d at

nat

iona

l le

vel a

nd d

isse

min

ated

Esta

blis

h an

d su

ppor

t da

ta

man

agem

ent

prog

ram

(D

MU

) at

the

nat

iona

l lev

el

Hol

d a

mee

ting

for

the

mem

bers

of

data

m

anag

emen

t pr

ogra

m t

o de

velo

p TO

RsH

old

a 2

day

retr

eat

to c

ompl

ete

the

data

man

agem

ent

man

ual a

nd S

OPs

5n/

a5

Hol

d a

2 da

y re

trea

t to

rev

iew

the

dat

a m

anag

emen

t m

anua

l and

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Ps5

n/a

Prin

t 3,

500

copi

es d

ata

man

agem

ent

man

ual a

nd S

OPs

n/a

Prin

t 3,

500

copi

es

of

revi

ewed

da

ta

man

agem

ent

man

ual a

nd S

OPs

n/a

Hol

d a

1 da

y m

eeti

ng t

o di

ssem

inat

e da

ta m

anag

emen

t m

anua

ls a

nd S

OPs

to

cou

ntie

s

n/a

Hol

d a

1 da

y m

eeti

ng t

o di

ssem

inat

e re

view

ed

data

m

anag

emen

t m

anua

ls

and

SOPs

to

coun

ties

n/a

Use

co

urie

r to

di

stri

bute

da

ta

man

agem

ent

man

ual a

nd S

OPs

n/a

Use

cou

rier

to

dist

ribu

te r

evie

wed

dat

a m

anag

emen

t m

anua

l and

SO

Ps

Prop

orti

on

of

coun

ties

de

velo

ping

an

d di

ssem

inat

ing

data

pr

oduc

ts

at

leas

t on

ce

ever

y 6

mon

ths

Proc

ure

data

ana

lysi

s so

ftw

are

Proc

ure

a da

ta a

naly

sis

and

map

ping

so

ftw

are

n/a

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50%

75%

Trai

n m

embe

rs

of

data

m

anag

emen

t pr

ogra

m o

n da

ta

anal

ysis

and

man

agem

ent

Hol

d a

5 da

y tr

aini

ng f

or m

embe

rs o

f da

ta

man

agem

ent

prog

ram

on

da

ta

anal

ysis

and

man

agem

ent

n/a

Hol

d a

refr

eshe

r co

urse

for

mem

bers

of

DM

Un/

a

Prop

orti

on o

f su

b-co

unti

es w

ith

tim

ely

repo

rts

and

mon

thly

re

turn

s

Prov

ide

tabl

ets

for

use

in t

he

surv

eilla

nce

syst

emPr

ocur

e

100

tabl

ets

fo

r ce

ntra

l pr

ogra

m s

taff

and

new

ly r

ecru

ited

fie

ld

TB m

anag

ers

100%

Proc

ure

100

tabl

ets

for

repl

acem

ent

of

old

stoc

k an

d ne

wly

rec

ruit

ed f

ield

TB

man

ager

s

100%

Proc

ure

100

tabl

ets

for

repl

acem

ent

of

old

stoc

k an

d ne

wly

re

crui

ted

fiel

d TB

man

ager

s

100%

Proc

ure

100

tabl

ets

for

repl

acem

ent

of

old

stoc

k an

d ne

wly

rec

ruit

ed f

ield

TB

man

ager

s

100%

Insu

re o

f ta

blet

sIn

sure

100

new

tab

lets

Insu

re 1

00 n

ew t

able

tsIn

sure

100

new

tab

lets

Insu

re 1

00 n

ew t

able

ts

Prov

ide

supp

ort f

or c

onti

nuou

s ru

nnin

g of

TIB

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mPr

ovid

e m

onth

ly

inte

rnet

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ndle

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r 40

0 ta

blet

s fo

r ru

nnin

g of

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ovid

e m

onth

ly i

nter

net

bund

les

for

400

tabl

ets

for

runn

ing

of T

IBU

Prov

ide

mon

thly

inte

rnet

bun

dles

for

400

tabl

ets

for

runn

ing

of T

IBU

Prov

ide

mon

thly

int

erne

t bu

ndle

s fo

r 40

0 ta

blet

s fo

r ru

nnin

g of

TIB

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Prov

ide

clou

d ho

stin

g of

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data

Prov

ide

clou

d ho

stin

g fo

r co

ntin

uous

ho

stin

g of

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ata

Prov

ide

clou

d ho

stin

g fo

r co

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uous

ho

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g of

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ata

Prov

ide

clou

d ho

stin

g fo

r con

tinu

ous

host

ing

of T

IBU

dat

aPr

ovid

e cl

oud

host

ing

for

cont

inuo

us

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dat

a

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ide

inte

rnet

co

nnec

tivi

ty

for

TIBU

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aPa

y m

onth

ly/a

nnua

l in

tern

et

fee

to

safa

rico

m f

or c

onne

ctiv

ity

to T

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dat

a ho

sted

in t

he c

loud

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mon

thly

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ual

inte

rnet

fe

e to

sa

fari

com

for

con

nect

ivit

y to

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ata

host

ed in

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clo

ud

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thly

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ual

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rnet

fee

to

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ctiv

ity

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da

ta h

oste

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clo

ud

Pay

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thly

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ual

inte

rnet

fe

e to

sa

fari

com

for

con

nect

ivit

y to

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ata

host

ed in

the

clo

ud

Ensu

re

inte

rnet

co

nnec

tivi

ty

for

NTL

D-

Prog

ram

Prov

ide

both

fix

ed a

nd w

irel

ess

inte

rnet

co

nnec

tivi

ty t

o N

TLD

Pro

gram

Prov

ide

both

fixe

d an

d w

irel

ess

inte

rnet

co

nnec

tivi

ty t

o th

e N

TLD

Pro

gram

Prov

ide

both

fi

xed

and

wir

eles

s in

tern

et

conn

ecti

vity

to

N

TLD

Pr

ogra

m

Prov

ide

both

fix

ed a

nd w

irel

ess

inte

rnet

co

nnec

tivi

ty t

o N

TLD

Pro

gram

Num

ber

of d

ownt

ime

epis

odes

pe

r m

onth

fo

r th

e N

TLD

Pr

ogra

m in

tern

et

Secu

re

TIBU

da

ta

by

havi

ng

back

up a

t N

TLD

Pro

gram

n/a

6Pr

ocur

e 2

serv

ers

wit

h re

leva

nt

soft

war

e fo

r da

ta b

acku

p an

d in

stal

l th

em a

t th

e N

TLD

Pro

gram

6C

onti

nuou

s up

date

of

back

dat

a in

th

e se

rver

5C

onti

nuou

s up

date

of

back

dat

a in

the

se

rver

4

4.3.

8. M

onit

orin

g an

d Ev

alua

tion

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Impr

ove

the

curr

ent

emai

l ho

stin

g to

Goo

gle

Clo

ud f

rom

gr

oup

wis

e

Mov

e cu

rren

t em

ail

host

ing

to G

oogl

e C

loud

fro

m g

roup

wis

e an

d op

en e

mai

l ac

coun

ts f

or a

ll N

TLD

Pro

gram

sta

ff

Prov

ide

cont

inuo

us

mai

ntan

ance

of

em

ail

acco

unts

for

all

NTL

D P

rogr

am

staf

f

Prov

ide

cont

inuo

us m

aint

anan

ce o

f em

ail a

ccou

nts

for

all N

TLD

Pro

gram

st

aff

Prov

ide

cont

inuo

us

mai

ntan

ance

of

em

ail

acco

unts

for

all

NTL

D P

rogr

am

staf

f

Proc

ure

com

pute

rs fo

r 5 m

odel

co

unti

es

for

impl

emen

tati

on

of

TIBU

at

co

unty

an

d su

b co

unty

fac

iliti

es

n/a

n/a

Proc

ure

and

prov

ide

com

pute

rs t

o th

e co

unty

and

sub

-cou

nty

faci

litie

s in

5 m

odel

cou

ntie

s

n/a

Num

ber

of

cum

ulat

ive

ORs

co

nduc

ted

and

docu

men

ted

Reva

mp

the

rese

arch

ta

sk

forc

e at

the

nat

iona

l lev

el a

nd

advo

cate

for

sim

ilar

foru

ms

at

coun

ty l

evel

; pr

omot

e im

pact

as

sess

men

t an

d pr

iori

tize

re

sear

ch,

incl

udin

g O

R th

at

will

ad

dres

s pr

ogra

mm

e ch

alle

nges

Hol

d on

e m

eeti

ng to

dra

w T

ORs

fo

r the

ta

skfo

rce

and

nom

inat

e th

e m

embe

rs5

Hol

d qu

arte

rly

rese

arch

ta

skfo

rce

mee

ting

s5

Hol

d qu

arte

rly

rese

arch

ta

skfo

rce

mee

ting

s5

Hol

d qu

arte

rly

rese

arch

ta

skfo

rce

mee

ting

s5

Build

the

capa

city

of

mem

bers

of

the

res

earc

h ta

skfo

rce

Con

duct

a

3 da

y tr

aini

ng

for

the

task

forc

en/

aC

ondu

ct a

3 d

ay

refr

eshe

r tr

aini

ng

for

the

task

forc

en/

a

Dev

elop

a

trac

king

sy

stem

fo

r nu

mbe

r o

f pe

ople

tra

ined

on

OR

and

num

ber

of s

tudi

es

cond

ucte

d

Enga

ge d

atab

ase

deve

lope

rC

onti

nous

use

of

the

syst

emC

onti

nous

use

of

the

syst

emC

onti

nous

use

of

the

syst

em

Dev

elop

a

crit

eria

fo

r id

enti

fica

tion

of

OR

trai

nees

hold

1

day

ta

skfo

rce

mee

ting

to

deve

lop

the

crit

eria

for

OR

trai

nees

n/a

Hol

d 1

day

task

forc

e m

eeti

ng

to

deve

lop

the

crit

eria

for

OR

trai

nees

n/a

Supp

ort

the

rese

arch

tas

kfor

ce

in

unde

rtak

ing

coun

ty

leve

l m

ento

rshi

p se

ssio

ns

n/a

Hol

d,1,

3 d

ay

join

t ta

skfo

rce,

men

tor/

men

tee

men

tors

hip

wor

ksho

pH

old

1,

3 da

y

join

t ta

skfo

rce

, m

ento

r/m

ente

e m

ento

rshi

p w

orks

hop

Hol

d 1

,3 d

ay

join

t ta

skfo

rce,

men

tor/

men

tee

men

tors

hip

wor

ksho

p

Prop

orti

on

of

trai

ned

men

tees

w

ith

com

plet

ed

and

docu

men

ted

OR

Build

ca

paci

ty

of

fiel

d TB

m

anag

ers

on

impa

ct

asse

ssm

ent

and

OR

hold

a 5

day

tra

inin

g fo

r 25

fie

ld T

B m

anag

ers

on O

R30

%H

old

a 5

day

trai

ning

for

100

fie

ld T

B m

anag

ers

on O

R80

%H

old

a 5

day

trai

ning

for

100

fiel

d TB

m

anag

ers

on O

R>

80%

Hol

d a

5 da

y tr

aini

ng f

or 5

0 fi

eld

TB

man

ager

s on

OR

>80

%

Prop

orti

on o

f tr

aine

d m

ente

es

atte

ndin

g an

d pr

esen

ting

in

di

ssem

inat

ion

mee

ting

s

Con

duct

bi

annu

al

foru

ms

to

shar

e re

sear

ch f

indi

ngs

at t

he

coun

ty le

vel

n/a

Hol

d 2

mee

ting

s fo

r ta

rget

ing

OR

men

tee

and

men

tors

to

shar

e pr

ogre

ss,

good

pra

ctic

es a

nd c

halle

nges

.

>90

%H

old

2 m

eeti

ngs

for

targ

etin

g O

R m

ente

e

and

men

tors

to

sh

are

prog

ress

, go

od

prac

tice

s an

d ch

alle

nges

>90

%H

old

2,

2 da

ys m

eeti

ngs

for

targ

etin

g O

R m

ente

e

and

men

tors

to

sh

are

prog

ress

,goo

d pr

acti

ces

and

chal

leng

es.

>90

%

Num

ber

of

conf

eren

ces

held

an

d do

cum

ente

dC

ondu

ct b

ienn

ial

lung

hea

lth

conf

eren

ces

n/a

Hol

d m

onth

ly

secr

etar

iat

mee

ting

s in

pr

epar

atio

n fo

r th

e bi

enni

al

lung

co

nfer

ence

1n/

aH

old

mon

thly

se

cret

aria

t

m

eeti

ngs

in

prep

arat

ion

for

the

bien

nial

lu

ng

conf

eren

ce

1

Hol

d sc

ient

ific

re

view

co

mm

itte

e m

onth

ly m

eeti

ngs

for

3 si

x m

onth

sH

old

scie

ntif

ic

revi

ew

com

mit

tee

mon

thly

mee

ting

s fo

r 3

six

mon

ths

Hol

d 3

days

bi

enni

al

lung

he

alth

co

nfer

ence

for

800

pax

Hol

d 3

days

bi

enni

al

lung

he

alth

co

nfer

ence

for

800

pax

Fina

l dr

ug

resi

stan

ce

suve

y re

port

s de

velo

ped

and

shar

ed

thro

ugh

web

site

Con

duct

Dru

g Re

sist

ant

Surv

ey

Dat

a co

llect

ion,

an

alys

is

and

repo

rt

wri

ttin

gH

old

a on

e da

y m

eeti

ng t

o di

ssem

inat

e fi

ndin

gs o

f dr

ug r

esis

tanc

e su

rvey

to

stak

ehol

ders

1n/

an/

a

Fina

l pr

eval

ence

suv

ey r

epor

ts

deve

lope

d an

d sh

ared

thr

ough

w

ebsi

te

Con

duct

Pre

vale

nce

surv

ey

Com

plet

e de

velo

pmen

t of

sur

vey

SOP

Con

duct

a 3

day

trai

ning

of t

he re

sear

ch

pers

onne

lH

old

a on

e da

y m

eeti

ng

to

diss

emin

ate

find

ings

of

prev

alen

ce

surv

ey t

o st

akeh

olde

rs

1n/

a

Map

ping

of

all t

he e

ligib

le p

arti

cipa

nts

Con

duct

dat

a da

ta c

olle

ctio

n, a

naly

sis

and

repo

rt w

ritt

ing

n/a

n/a

4.3.8. Monitoring and Evaluation

Mon

itor

ing

and

Eval

uati

on O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

itiv

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Proc

urin

g of

sur

vey

equi

pmen

tH

old

a on

e da

y m

eeti

ng t

o di

ssem

inat

e fi

ndin

gs

of p

reva

lenc

e su

rvey

to

100

stak

ehol

ders

Recr

uitm

ent

of r

esea

rch

per

sonn

eln/

a

Fina

l su

rvey

on

de

lay

in

diag

nosi

s de

velo

ped

and

shar

ed

thro

ugh

web

site

Con

duct

a s

urve

y on

Del

ay i

n D

iagn

osis

C

ompl

ete

fiel

d da

ta c

olle

ctio

nH

old

a on

e da

y m

eeti

ng t

o di

ssem

inat

e fi

ndin

gs

of d

elay

dia

gnos

is

surv

ey t

o 10

0 st

akeh

olde

rs

1n/

an/

a

Con

duct

da

ta

an

alys

is

and

repo

rt

wri

ting

n/a

Fina

l m

orta

lity

surv

ey

repo

rts

deve

lope

d an

d sh

ared

thr

ough

w

ebsi

te

Con

duct

a M

orta

lity

Surv

ey

n/a

Dev

elop

su

rvey

pr

otoc

ol

and

data

co

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4.3.9. Enabling environment

4.3.9.1. Policy1. Situational Analysis

The rapidly evolving health system, including devolution and a move toward universal health coverage, will require adaptations in how the NTLD Program operates. Tuberculosis, leprosy and lung health will need to become part of essential health package that is formed on the basis of emerging/expanding demand-side, performance-based and social support financing schemes. For example, the direct facility cash transfer program called the Health Sector Services Fund (HSSF) or the health insurance for poor families called the Health Insurance Subsidy Programme (HISP), does not currently include TB prevention and control services.

Over the next three (3) years, it is estimated that the NTLD Program will face a financing gap totaling 50% of its required funding. Data from the National Health Accounts (NHA) suggested that while TB accounts for over 6% of deaths and nearly 5% of DALYs in the country, it receives only 1% of total health expenditures for priority areas. This is in contrast to malaria’s contribution to nearly 6% of deaths and 7% of DALYs, but in receipt of 25% of total health expenditures for priority areas.

TB particularly harms the poor in Kenya. Over half of patients are malnourished, to some degree, at the onset of treatment, with 17% being severely malnourished and a further 22% being moderately malnourished. Poor nutritional status is known to negatively impact treatment adherence and outcomes1. A review of case notifications by county poverty rate demonstrated that case finding is lagging in the poorest counties. It is not known if this is a reflection of the actual epidemiology or barriers to care, but it is cause for concern and should be further investigated. The majority of nutrition support programs that can benefit TB patients target women and children, leaving male TB patients without equitable access.

2. Strategic Direction(s) for 2015-2017

The priority is to position the activities of the NTLD Program within the priorities of the health sector, social protection agenda, and other relevant sectors. Ensuring the full integration of TB within county priorities and national financing of universal health care is similarly important.

3. Proposed Approaches

Actively participate in national policy and planning process in the move towards universal health coverage, ensuring that TB and leprosy control are appropriately positioned.

i. Articulate the investment case for TB control in Kenya, with targeted policy briefers to inform county and national level policy-development. It may be necessary to change perceptions that TB and leprosy are sufficiently funded or can operate sustainably on supply-side financing.

ii. Define the reimbursement package that would be required to fully reimburse service delivery providers for the care of a TB or MDR-TB case. Ensure that these are made available to the NHIF, for the purposes of consideration under the HISP and other future insurance schemes.

iii. Ensure the inclusion of TB and leprosy where appropriate, in broad sector strategies and initiatives. Actively collaborate across the MoH, including with NHA, NACC, NASCOP, and Policy and Planning; with other sectors such as labor, education, and social protection; and with external partners working on devolution, such as the World Bank.

Some of the immediate needs include:

_______________________________________________________________________________________________________________________________1 http://digitalcommons.calpoly.edu/cgi/viewcontent.cgi?article=1009&context=fsn_fac

4.3.

9.1

Enab

ling

Envi

ronm

ent:

Pol

icy

117

4.3.9.1 Enabling Environment: Policy

1. Social protection: Develop a strategy to enhance linkages to social protection schemes by TB patients: e.g. nutritional, transportation and cash support.

2. Monitor the impact (positive and negative) of devolution and emerging financing modalities on TB case notifications and treatment outcomes, with a view to learning lessons for scale-up of what works.

NTLD Program to actively seek to expand its partner base; to facilitate the mainstreaming of programme priorities into the devolution and Universal Health Care (UHC) processes.

i. Systematic collaboration with other government actors should include National Health Accounts (NHA), Treasury, MoH Policy and Planning division, Social Protection, Ministry of Labor (workplace-based DOTS and labor policy to protect TB and leprosy patients), Ministry of Education (potential information raising and TB screening in schools) and NACC (TB/HIV).

ii. Engaging non-governmental partners and donors who are key partners in the health sector such as the World Bank and DANIDA, to ensure that TB and leprosy are well integrated in emerging pro-poor, insurance and social protection strategies.

iii. Seek to harmonize efforts with other disease programs within the communicable diseases division, e.g.1. Integrate other communicable diseases within TIBU, or a TIBU-like system 2. Single planning/financing tool (e.g. WHO TB financing tool, simplified)3. Shared capacity building activities4. Shared advocacy to counties for appropriate priority-setting and planning for communicable diseases5. Hire an economist and statistician at division level to support analytical work required to monitor impacts of

new technical approaches and devolved implementation.

Address the social determinants of TB through policy change and social protection schemes

i. Evaluate the financial barriers for TB patients as part of the prevalence survey, or conduct participatory poverty assessments (PPAs) to prioritize social health protection measures that would best support TB patients.

ii. Identify and explicitly remove the financial barriers contributing to diagnostic delay and at the point of care; e.g. promote free diagnostic services for children

iii. Evaluate the impact of current nutritional support programs on TB case finding and treatment outcomes. Explore the expansion of programs to include male TB patients

iv. Pilot test the inclusion of TB in a demand-side financing model as part of the roll-out of HISP, which includes a transport subsidy.

Update national policies

i. Make x-rays and Xpert testing free for children. The financial barriers to diagnosis may delay notification of childhood TB cases. Consideration should be given to removing the financial cost of diagnostic tests to all presumptive TB patients, particularly for the poor and among those living with HIV.

ii. Establish enforcement modalities for mandatory notification of TB, leprosy and lung diseases by private providers

iii. Establish legal framework to protect TB and leprosy patients from workplace-based discrimination

iv. Make mandatory the inclusion of TB and leprosy benefits within insurance packages (public and private)

v. Establish TB and leprosy as qualifying events for access to social protection benefits

vi. Introduce Xpert as the 1st diagnostic tool for PLHIV, children, retreatment cases, refugees and health care workers

vii. Add PAL medications; e.g. inhalers, to the essential drugs list.

118

4.3.9.2. Advocacy and communications

1. Situational Analysis

Given current resource availability, the NTLD Program estimates that there will be a budget shortfall of more than 50% of the total required to fully implement this NSP.

Increasing government investments in TB, leprosy and lung health will require political commitment and resource prioritization by not only the central government but also by the county governments. It will require that the programme realize efficiency gains through the integration of TB and leprosy control activities into other service delivery platforms (e.g. MCH), financing modalities (e.g. insurance schemes), and policies (e.g. workplace). Complementary and increased funding from donors and partners will be needed to sustain core activities and enable the roll-out of new innovations. In all cases, targeted communication and advocacy to the respective constituencies will need to be developed and delivered.

According to Kenya Demographic and Health Survey (KDHS, 2009), 98% of men and women in Kenya have heard about TB, with 89% of women and 92% of men recognizing that it can be cured. The KDHS suggested that stigma persists, with 25% of women and 10% of men noting that if a family member had TB, they would want to keep it a secret. In rural areas, knowledge about TB is significantly less common and stigma is higher than in urban settings1. The only TB-specific Knowledge, Attitudes and Practice (KAP) surveys done recently were among school children, and do not adequately guide planning.

Despite widespread general knowledge, care seeking is commonly delayed. Studies from various regions within Kenya have shown care seeking and diagnostic delays ranging from weeks to months. Furthermore, almost 5% of patients default from treatment.

There is anecdotal evidence suggesting that provider perceptions about the effectiveness and impact of some interventions, such as the provision of IPT, limit their willingness to deliver these services. Among health care workers who develop TB, treatment success rate is lower (75%) than in the general population (>85%), suggesting stigma or other constraints to treatment adherence.

A communication and advocacy strategy was developed by the NTLD Program in 2012, but has not been implemented.

2. Strategic Direction(s)

Communications and advocacy efforts will contribute to the acceleration of case detection and increase of treatment success rate by ensuring that relevant information and targeted messages reach those who can influence individual, community, provider, government or donor behavior. Mobilization of political will and resources, financial and human, is a priority for advocacy-related activities.

3. Proposed Approaches

The proposed approaches outlined below respond to the recognition that different programmatic needs are best addressed by advocacy and communication activities that target different audiences. (See Figure 31)

A foundational economic and social investment case for TB, leprosy and lung health will be developed, from which messaging for many of the constituencies highlighted below can be derived; i.e. framing the case for “why invest in TB, leprosy and lung health” at all levels of the government, and among partners, communities and households.

_______________________________________________________________________________________________________________________________1 Demographic and Health Survey, Kenya; 2008-9

4.3.

9.2

Adv

ocac

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d Co

mm

unic

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119

Figure 30: Weekly Use of Information Sources

4.3.9.2: Advocacy and Com

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Package 1: Build political will and mobilize resources at county government level

Building political will and mobilizing resources for TB, TB/HIV, leprosy and lung health at the county level will require that the burden of these diseases in each county be contextualized. Situational analyses that build on this NSP are planned for each county that should yield baseline information and propose county-specific targets to be monitored, including programme performance, financial commitments and disbursement, and funding gaps per county. These county-specific advocacy and communications plans will take into account the local challenges and opportunities described in the section on Core DOTS. Opportunities for resource mobilization in support of counties with limited local resources will be prioritized.

Issues related to the control of TB, leprosy and lung health can be incorporated into county health fora. The NSP supports the establishment of a STOP TB Partnership office to coordinate communication and advocacy efforts in every county with CNR >175/100,000 as these are areas with multiple partners and high needs. Furthermore, medical parliamentarians (i.e. members of parliament on the health committee) will be engaged to promote local political will in their home areas.

Some illustrative activities under this package include: a) hosting a breakfast meeting during the Governors’ council just before the annual work planning process; b) convening of county stakeholder meetings to review health budgets against yardsticks for funding allocations; c) identify TB champions for each county; d) develop TB portals within each county’s website.

Package 2: Build political will and mobilize resources at national government level

The existing communications and advocacy plan does not sufficiently respond to the redefinition of central level roles and responsibilities. The NTLD Program must enhance communications and advocacy across the central government, broadening ownership of the programme and integrating TB, leprosy and lung health issues into social protection schemes and other health and non-health sector development plans.

The engagement of the Parliamentary Health Committee and the Senate will be sought, with regular briefs provided by the NTLD Program. The NTLD Program must concurrently facilitate access to information about the diseases and its programs among the citizenry and stakeholders. Finally, the central NTLD Program must operationalize its increased communication and advocacy role vis-à-vis the counties. The national communications and advocacy strategy will therefore be updated. KAP evidence will emerge as part of the national prevalence survey and can enhance the update.

Package 3: Build political will and mobilize resources at donor level

The NSP has dual objectives of sustaining close collaboration with existing donors and nurturing new donor partnerships. National and county-level Stop TB Partnerships will be supported to engage new donors from the private and other non-state sectors, including businesses. The NTLD Program and its partners will proactively and creatively mobilize new funds through events, such as races, rhino charge; and innovative financing, e.g. tax breaks, charity pledges. A database of existing and potential donors will be established to better target resource mobilization where large gaps remain.

Figure 31: Communications and Advocacy Framework

120

Package 4: Accelerate case detection and increase treatment success through health providers

To ensure health providers have all the relevant technical information as well as the motivation to provide quality services, activities are planned to: a) disseminate existing tools; b) develop new communication and advocacy materials targeting the specific needs of HCWs, such as tools for adherence counseling and health education, fact sheets on IPT and contact tracing. Motivating HCWs through professional development opportunities and performance-based recognition will form part of the advocacy strategy.

The NTLD Program will update pre-service and in-service medical training for all cadres of personnel to ensure that training is consistent with the norms and policies of the NTLD Program. Key faculty will be engaged to design and deliver potentially online, short courses or modules that communicate the components of NTLD Program guidelines. These modules and courses will be promoted as integral components of pre-service training.

Package 5: Reduce stigma, accelerate care seeking, and enhance case holding through communities

New communication materials and messages, including print, radio and mobile-phone based (depending on the local context), will be developed and translated for use at community level. Tools will be developed and activities supported to empower CHEWs, CSOs, religious leaders and other community leaders to inform, educate and support their patients, patient families and communities. TB, leprosy and lung health activities will be integrated into the training curriculum and terms of reference for CHEWs.

Similarly, tools to facilitate the referral of presumptive and confirmed patients between health facilities and the community will be developed. Tools to engage informal providers such as drug sellers, and to engage workplaces in the referral of presumptive cases, will also be developed. The NTLD Program will incorporate TB, leprosy and lung health messages into community health days and other health-related platforms at community level.

A specific focus on gender-based differences in knowledge, care seeking and treatment adherence will render gender-specific activities. For example, male-specific clubs led by male, former TB patients/champions will focus on overcoming the higher rate of default among men.

Package 6: Increase awareness of symptoms among patients and their expectations during treatment

Communication efforts targeting patients aim to provide information and resources to successfully complete treatment. Former and current TB patients, especially amonth the youth, will be engaged in crafting the messages and determining the best delivery platforms, e.g. web-based, social media, SMS, health workers.

The NTLD Program will consider how to best deliver information, based on known access to different forms of communication (See Figure 32). Existing tools, such as the patient charter (International Standards of Tuberculosis Care 2014), will be updated and made available to all DOT supporters. An interactive website and TB hotline will be hosted to facilitate confidential communication channels for patients.

Patient-centered communication will be developed in collaboration with the relevant partners, to refer TB, leprosy and lung health patients to social protection schemes, social support systems, and income generation activities. This messaging will evolve as the NTLD Program mobilizes support for the inclusion of TB and leprosy patients in social protection. Advocacy to partners to establish incentives for patients to complete treatment; e.g. Bata Shoe Co. voucher, will be pilot tested in selected areas with low treatment success.

Figure 32: Access to Information and Communication Technologies

4.3.

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4.3.

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Adv

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unic

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4.3.9.3 Gender and H

uman Rights

4.3.9.3. Human rights and gender1. Introduction

Human rights are universal legal guarantees protecting individuals and groups against actions that interfere with fundamental freedoms and human dignity. Gender refers to the social attributes and opportunities associated with being male or female and the relationships between women and men and girls and boys, as well as the relations between women and those among men. Gender determines what is expected, allowed and valued in a woman or a man in a given context. Gender equity is the absence of discrimination on the basis of a person’s sex, especially in connection with opportunities, allocation of resources or benefits and access to services. Gender equality entails the provision of fairness and justice in the creation of opportunities, distribution of benefits and responsibilities between women and men/girls and boys1. Gender mainstreaming is the strategy used to achieve equality in both women and men. For the case of TB, leprosy and lung diseases, this would mean integrating gender concerns into all laws, policies, regulations and programs concerning TB, leprosy and lung diseases care prevention and management.

The human rights based approach to programming is a process that infuses key human rights principles into programming with a view to ensuring that programs effectively address what they set out to, and produce an outcome that is desirable, sustainable, entrenched, and fully owned by the community. The human rights based approach aims at achieving a desirable outcome by focusing on the rights of the people the program intends to benefit. The key human rights principles that form part of the rights based approach are equality and non-discrimination, participation, accountability and people centered approaches. Human rights based approach in the case of TB, leprosy and lung diseases would involve integrating human rights principles in the design, implementation, monitoring and evaluation of TB, leprosy and lung diseases programs.

2. How human rights and gender impact on TB, leprosy and lung diseases

When human rights principles are not respected, and when gender inequalities are not taken into account, people are likely to be more vulnerable to TB, leprosy and lung disease infections. This is because they are less likely to access available services due to the barriers created by failing to address the human rights and gender barriers2. Key vulnerable groups in the context of TB, leprosy and lung diseases are more likely to be exposed to conditions that are conducive to TB, leprosy and lung diseases development, and less likely to have the information, power and resources necessary to ensure their access to health services. The stigma and discrimination associated with TB, leprosy and lung diseases, the and overlapping discrimination based on gender, poverty, or HIV status, can affect people’s employment, housing and access to social services3. Gender inequalities can impact health risks, health seeking behavior and responses from health systems, leading to poorer outcomes for everyone. It is thus important to address the different needs of women and men, girls and boys taking into account their diversity. This may involve undertaking gender responsive programming where one takes into account the prevailing gender norms or undertaking gender transformative programming, where one seeks to change harmful gender norms that act as a barrier to accessing health services4.

3. Country context on human rights and gender

The Constitution of Kenya 2010 provides the main legal framework to ensure a comprehensive rights-based to health services delivery. All laws and policies must be in line with the provisions of the Constitution of Kenya 2010. The Constitution makes provision for the right to the highest attainable standard of health, which includes reproductive health rights. It makes provision for people not to be denied emergency medical treatment, and obligates the State to provide appropriate social security to persons who are unable to support themselves and their dependents5.

The Constitution obligates the State and every state organ to observe, respect, protect, promote and fulfill the rights in the constitution and to take “legislative, policy and other measures, including setting of standards, to achieve the progressive realization of the rights guaranteed in Article 43.” State organs and public officers have a constitutional obligation to address the needs of the vulnerable groups6 in society and to domesticate the provisions of any relevant international treaty that Kenya has ratified7.

Article 46 of the Constitution makes provision for the protection of consumer rights, including the protection of health safety and economic interests. Article 27 of the Constitution outlaws discrimination on the basis of one’s health status. It provides for equality between men and women, and takes into account the use of affirmative action programs and policies to redress any disadvantage suffered by people because of past discrimination. The Constitution has provided

_______________________________________________________________________________________________________________________________1 Available at http://www.un.org/womenwatch/osagi/conceptsandefinitions.htm accessed on 1st August 2014. 2 UNDP (2013). Discussion Paper: The Role of Human Rights in Responses to HIV, Tuberculosis and Malaria. http://www.undp.org/content/dam/undp/library/hivaids/English/TheRoleofHRinResponsestoHIVTB, leprosy and lung diseases Malaria-UNDP-DP-web.pdf 3 Global Fund Information Note: Human Rights for HIV, TB, leprosy and lung diseases, Malaria and HSS Grants (February 2014) Available at http://www.the-globalfund.org/en/fundingmodel/support/infonotes/4 Global Fund (April 2014) Information Note Addressing Gender Inequalities and Strengthening Responses for Women and Girls Available at http://www.the-globalfund.org/en/fundingmodel/support/infonotes/5 Article 43 of the Constitution of Kenya 2010 Available at http://kenyalaw.org/kl/index.php?id=398 6 These include women, older members of society, persons with disabilities, children, and youth, members of minority or marginalized communities and mem-bers of particular ethnic and religious or cultural communities.7 Article 2(6) of the Constitution recognizes ratified international treaties as part of the laws of Kenya.

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values and principles, which all state organs and officers are expected to employ in the delivery of services. The principles are captured in Articles 10 and 232, Chapter 6 and 12 of the Constitution. The relevant articles of the Constitution that touch on the right to health are Articles 2, 10, 20, 26, 27, 43, 53-57 and 174.

The Public Health Act Chapter 242 of the Law of Kenya8 has provisions under Section 27 which allows for the isolation of persons who have been exposed to infection9. Section 28 of the Act makes it an offence to willfully expose others to an infectious disease. These sections of the law, in the case of TB, leprosy and lung diseases management, have been the subject of a number of court decisions that have challenged the manner in which the Sections have been enforced10. The courts have also sought clarification on the contemplated place of isolation11. The country is in the process of developing a health law and policy that are equally likely to impact TB, leprosy and lung diseases management.

Gender factors influence epidemiological differences in exposure, risk of infection and progression from infection to disease. In Kenya, men between 24-40 years have higher TB, leprosy or lung disease burden and are more likely to default from treatment. In 2013, among smear positive pulmonary TB, leprosy and lung diseases patients, aged 15-54 years, men were twice as affected by TB, leprosy and lung diseases than females. Male gender norms in many contexts mean that men have delayed health-seeking behavior. Women are more susceptible to HIV12 and HIV is a risk factor for TB, leprosy and lung diseases. The lower numbers could be caused by structural barriers, limited access to resources, information and time. This raises the question about the possibility that women are not coming out for treatment, for example13. Focused efforts are needed to diagnose, treat and prevent TB, leprosy and lung diseases among women. Societal structures see a majority of women not enjoying the same rights, opportunities and access to health services as men, placing them at greater risk and at a disadvantage with respect to treatment and care. Their access to information and finances, in many contexts, is determined or controlled by men as heads of households, who often have greater economic power14. These differences should be taken into account when developing strategies for interventions in the tuberculosis, lung diseases and leprosy programs.

4. Gaps and challenges on human rights and gender in the context of TB, leprosy and lung diseases

Some of the identified gaps and challenges on issues relating to gender and human rights in the context of TB, leprosy and lung diseases include:

• Inaccessibility to quality health care e.g. barriers of gender, age, type of disease, social setting, geographical barriers, distances and inability to pay.

• Prevalent and increasing levels of poverty amongst the vulnerable groups.• Legal and policy barriers that hinder optimal provision of services to the key and vulnerable populations. • Inadequate interventions to address management and infection control for TB, leprosy and lung diseases cases and

mainstream gender and human rights needs and concerns.• Inadequate knowledge on gender and human rights among the general public and key stakeholders.• Inadequate national baseline data revealing the relationship of gender and human rights, including social, cultural

and economic factors in interventions for TB, leprosy and lung diseases.• Reluctance to embrace rights based approach to programming and service delivery for TB, leprosy and lung diseases

care, which takes into account gender concerns.

5. Strategic Priorities for 2015-2018

Monitoring and reforming laws, regulations and policies relating to TB, leprosy lung diseases

This can be achieved by the successful implementation of programs that address:

• Review of laws, policies and law enforcement practices to see whether they impact the response to TB, leprosy and lung diseases positively or negatively, taking into account the human rights and gender gaps.

• Assessment of access to justice for people infected with TB, leprosy and lung diseases or vulnerable to TB, leprosy and lung diseases infection.

• Advocacy and lobbying for law and policy reform with the relevant stakeholders on matters relating to TB, leprosy and lung diseases.

• Promotion of the enactment and implementation of laws, regulations and policies that prohibit discrimination and support access to TB, leprosy and lung diseases prevention, treatment, care and support.

• Develop tools to monitor incidents of rights violations, including discrimination, gender based violence and denial of health care services for TB, leprosy and lung diseases patients.

• Training community groups on how to use the tools and report incidents of human rights and gender based violations.

4.3.

9.3

Gen

der a

nd H

uman

Rig

hts

_______________________________________________________________________________________________________________________________8 Chapter 242 of the Laws of Kenya available at http://www.kenyalaw.org:8181/exist/kenyalex/actview.xql?actid=CAP.%20242 9 Available at kelinkenya.org/wp-content/uploads/2010/10/Advisory-Note-on-Arrest-of-TB, leprosy and lung diseases -Patients-in-Kapsabet.pdf 10 Available at kelinkenya.org/wp-content/uploads/2010/10/Misc-Criminal-App-No.-24-of-20111.pdf 11 Available at kelinkenya.org/wp-content/uploads/2010/10/Ruling-on-Petition-No.-3-of-2010.pdf 12 Kenya AIDS Indicator Survey 2012 Available at http://www.google.co.ke/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0C-CcQFjAA&url=http%3A%2F%2Fnascop.or.ke%2Flibrary%2F3d%2FPreliminary%2520Report%2520for%2520Kenya%2520AIDS%2520indicator%-2520survey%25202012.pdf&ei=K1nbU4-hF4bD7Aa774DwCQ&usg=AFQjCNEVSaGbVsyBVlgroBAlEUWSTlV2ZA&bvm=bv.72197243,d.ZGU 13 National Tuberculosis, Leprosy and Lung Disease Program 2014 Annual report http://www.nltp.co.ke/index.php?option=com_content&view=section&lay-out=blog&id=5&Itemid=38 14 Sexual Inequality in Tuberculosis; Oliver Neyrolles & Luis Quintana Available at http://www.oalib.com/paper/85316#.U9tiIGOcxco

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4.3.9.3 Gender and H

uman Rights

Removal of the legal, human rights and gender barriers to access to TB, leprosy and lung diseases services

This can be achieved by the successful implementation of programs that address:• Stigma and discrimination reduction programs that include community-based interventions (including media) that

provides accurate information about TB, leprosy and lung diseases transmission.• Conducting legal literacy (know your rights) campaigns to improve legal and human rights literacy of people infected

and affected by TB, leprosy and lung diseases in relation to the identified human rights and gender gaps based on the legal assessment.

• Provision of TB, leprosy and lung diseases-related legal services to those who face human right violations.• Active case finding in communities affected by TB, reaching out to women and other economically disadvantaged

who do not have means to access services without paying for transportation. Integrate TB services into Reproductive Maternal and Child Health (RMNCH)-related health services to facilitate access by women and girls.

Training of lawmakers, law enforcement agents and health care workers

This can be achieved by the successful implementation of programs that pursue the following:

• Sensitization of law makers, law enforcement agents regarding TB, leprosy and lung diseases, modes of transmission and the negative consequences of illegal police activity on justice and on the TB, leprosy and lung diseases response.

• Facilitated discussions and negotiations among TB, leprosy and lung diseases service providers, those who access services, and the police, to address law enforcement practices that impede prevention of TB, leprosy and lung diseases, treatment, care and support efforts.

• Information and sensitization sessions for parliamentarians, member of county assemblies, governors, judicial officers, prosecutors, lawyers, staff members of human rights and gender commissions, on the legal, health and human rights aspects of TB, leprosy and lung diseases and on relevant national laws and the implications for enforcement, investigations and court proceedings.

• Training for prison personnel regarding the prevention, health care needs and human rights of detainees infected with or at risk of TB, leprosy and lung diseases.

• Training to ensure that health care providers know about their rights to health (TB, leprosy and lung diseases prevention and treatment, universal precautions, compensation for work-related infection) and to non-discrimination in the context of TB, leprosy and lung diseases.

• Training to reduce stigmatizing attitudes in health care settings and to provide health care providers with the skills and tools necessary to ensure patients’ rights to informed consent, confidentiality, treatment and non-discrimination.

Formation of inter-sectoral partnerships between the Ministry of Health (NTLD Program) and other parts of government to embed TB, leprosy and lung diseases concerns

This can be achieved by the successful implementation of programs that:

• Sensitize relevant government staff to ensure equal access for TB, leprosy and lung diseases patients to agricultural subsidies, housing allocation and other social benefits.

• Sensitize government actors to mainstream, TB, leprosy and lung diseases considerations in national policies and programs relating to labor, nutrition/food security, housing/urban planning, corrections, social protection and other development initiatives.

• Sensitize National Human Rights Institutions, Gender Commission and Office of the Ombudsman, on human rights dimensions of TB, leprosy and lung diseases.

Research, knowledge management and M & E

This can be achieved by the successful implementation of programs that:

• Conduct a baseline survey to document the magnitude and nature of human rights violations and gender disparities in TB, leprosy and lung diseases, Leprosy and lung diseases.

• Conduct a baseline survey on social and economic impact of TB, leprosy and lung diseases.• Develop a TB, leprosy and lung diseases stigma index to measure TB, leprosy and lung diseases-related stigma in

communities and health care settings.

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4.3.

9.3

Gen

der a

nd H

uman

Rig

hts

Gen

der

and

Hum

an R

ight

s O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

1: M

onit

orin

g an

d re

form

law

s, r

egul

atio

ns a

nd p

olic

ies

rela

ting

to

TB

Ass

essm

ent

repo

rt o

f la

ws,

pol

icie

s an

d la

w e

nfor

cem

ent

prac

tice

s th

at

impa

ct p

osit

ivel

y or

neg

ativ

ely

on T

B

Aud

it o

f la

ws,

pol

icie

s an

d la

w

enfo

rcem

ent

prac

tice

s A

udit

th

e la

ws

and

polic

ies

and

deve

lop

a re

port

on

the

prac

tice

s an

d la

ws

on T

B H

R an

d ge

nder

1Im

plem

enta

tion

of

the

find

ings

of

the

audi

t an

d di

ssem

inat

ion

of t

he r

epor

tn/

aIm

plem

enta

tion

of

the

find

ings

of

the

audi

t an

d di

ssem

inat

ion

of t

he r

epor

tn/

a

Dra

ft

TB,

lepr

osy

and

lung

he

alth

di

seas

es b

illD

evel

op a

dra

ft T

B, l

epro

sy a

nd

lung

bi

ll1.

Hol

d co

nsul

tati

ve f

orum

s w

ith

key

stak

ehol

ders

an

d m

embe

rs

of

the

publ

ic a

t bo

th n

atio

nal

and

coun

ty

leve

ls

2.

Dra

ft T

B Le

pros

y an

d Lu

ng B

ill

1Pr

esen

t the

bill

to p

arlia

men

t thr

ough

th

e re

leva

nt c

omm

itte

e fo

r de

bate

n/

aA

dvoc

acy

and

lobb

y m

eeti

ngs

for

la

w

and

polic

y re

form

w

ith

the

rele

vant

st

akeh

olde

rs

on

mat

ters

re

lati

ng t

o TB

n/a

Prom

otio

n of

th

e en

actm

ent

and

impl

emen

tati

on

of

law

s,

regu

lati

ons

and

polic

ies

that

pro

hibi

t di

scri

min

atio

n an

d su

ppor

t ac

cess

to

TB

pr

even

tion

, tr

eatm

ent,

ca

re

and

supp

ort

thro

ugh

vari

ous

mee

ting

s an

d co

nsul

tati

ons

n/a

Num

ber

of

mon

itor

ing

tool

s di

ssem

inat

edD

evel

op

tool

to

m

onit

or

inci

denc

es

of

righ

ts

viol

atio

ns

incl

udin

g di

scri

min

atio

n, g

ende

r ba

sed

viol

ence

an

d de

nial

of

he

alth

ca

re

serv

ices

fo

r TB

pa

tien

ts

1. D

evel

op a

mon

itor

ing

tool

2.

Tes

t th

e to

ol in

one

cou

nty.

3. W

orks

hop

to i

ncor

pora

te c

hang

es

on t

ool b

ased

on

test

.

4.

Fin

alis

e to

ol a

nd r

oll o

ut t

ool

0D

isse

min

ate

the

tool

for

use

1,00

0A

naly

sis

of

data

co

llect

ed

and

utili

sati

on o

f th

e fi

ndin

gs t

o in

form

pr

ogra

mm

ing

1,00

0A

naly

sis

of d

ata

colle

cted

and

uti

lisat

ion

of t

he f

indi

ngs

to in

form

pro

gram

min

g1,

000

Num

ber

of T

OTs

tra

ined

on

hum

an

righ

ts is

sues

and

the

use

of

the

righ

ts

viol

atio

ns' m

onit

orin

g to

ol

Trai

ning

com

mun

ity

grou

ps o

n ho

w t

o us

e th

e to

ols

and

repo

rt

inci

denc

es o

f hu

man

rig

hts

and

gend

er b

ased

vio

lati

ons

Trai

n 30

tra

iner

s of

tra

iner

s (T

OT)

per

co

unty

in 1

0 pi

lot

coun

ties

300

Impl

emen

t us

e of

the

too

l, co

llect

ion

of i

nfor

mat

ion

and

anal

yses

of

data

co

llect

ed

and

utili

sati

on

of

the

find

ings

to

info

rm p

rogr

amm

ing

Impl

emen

t us

e of

the

too

l, co

llect

ion

of i

nfor

mat

ion

and

anal

yses

of

data

co

llect

ed

and

utili

sati

on

of

the

find

ings

to

info

rm p

rogr

amm

ing

Impl

emen

t us

e of

th

e to

ol,

colle

ctio

n of

in

form

atio

n an

d an

alys

es

of

data

co

llect

ed a

nd u

tilis

atio

n of

the

fin

ding

s to

info

rm p

rogr

amm

ing

Stra

tegi

c A

ppro

ach

2: R

emov

al o

f th

e le

gal,

hum

an r

ight

s an

d ge

nder

bar

rier

s

Val

ue o

f th

e st

igm

a in

dex

in h

ealt

h ca

re s

etti

ngs

and

com

mun

itie

sSt

igm

a an

d di

scri

min

atio

n re

duct

ion

prog

ram

mes

incl

udin

g ra

dio/

TB

and

prin

t ad

vert

s,

stig

ma

redu

ctio

n IE

C

Dev

elop

IE

C

mat

eria

ls

wit

h no

n-st

igm

atis

ing

mes

sage

s.75

%C

omm

unit

y in

tera

ctio

ns

and

disc

ussi

ons

tar

geti

ng

wom

en,

men

, yo

uth,

pe

rson

s w

ith

disa

bilit

ies,

el

derl

y, r

elig

ious

lea

ders

, hea

lth

care

pr

ovid

ers,

le

arni

ng

inst

itut

ions

an

d in

volv

ing

TB p

atie

nts

in 1

0 co

unti

es.

50%

Use

m

edia

in

clud

ing

skit

s,

play

s,

adve

rtis

emen

ts d

esig

ned

to e

duca

te

as w

ell

as t

o am

use

and

inte

grat

ion

of n

on-s

tigm

atis

ing

mes

sage

s on

TB

and

beha

viou

r ch

ange

int

o TV

and

Ra

dio

show

s

25%

1. C

omm

unit

y fo

rum

s an

d us

e of

the

m

edia

sh

ows

invo

lvin

g co

mm

unit

y re

cogn

ized

le

ader

s,

to

pass

no

n st

igm

atiz

ing

mes

sage

s.

2 En

gage

men

t w

ith

relig

ious

an

d co

mm

unit

y le

ader

s an

d ce

lebr

itie

s to

pr

omot

e no

n-st

igm

atis

ing

mes

sage

s on

TB

, Le

pros

y an

d be

havi

our

chan

ge in

10

coun

ties

15%

Num

ber

of p

eopl

e tr

aine

d, u

sing

new

hu

man

ri

ghts

an

d ge

nder

tr

aini

ng

mod

ule

Con

duct

ing

lega

l lit

erac

y (k

now

yo

ur

righ

ts)

cam

paig

ns

to

impr

ove

lega

l an

d hu

man

rig

hts

liter

acy

of p

eopl

e in

fect

ed a

nd

affe

cted

by

TB

in

re

lati

on

to

the

iden

tify

hu

man

ri

ghts

an

d ge

nder

gap

s ba

sed

on t

he l

egal

as

sess

men

t

Dev

elop

hum

an r

ight

s a

nd g

ende

r tr

aini

ng

mod

ules

an

d in

terg

rate

in

to T

uber

culo

sis,

Lep

rosy

an

d Lu

ng

Dis

ease

s tr

aini

ng p

rogr

am

Con

duct

the

tra

inin

gs o

f ta

rget

ttin

g 10

0 pe

ople

fro

m 5

cou

ntie

s10

0C

ondu

ct t

he t

rain

ings

of

targ

ettt

ing

200

peop

le f

rom

10

coun

ties

200

Con

duct

the

tra

inin

gs o

f ta

rget

ttin

g 1

00

peop

le f

rom

5 c

ount

ies

100

Perc

enta

ge

of

TB-r

elat

ed

hum

an

righ

ts

viol

atio

ns

for

whi

ch

lega

l se

rvic

es a

re p

rovi

ded

Prov

isio

n of

TB

re

late

d le

gal

serv

ices

to

th

ose

who

fa

ce

hum

an r

ight

vio

lati

ons

Trai

ning

law

yers

, re

pres

enta

tive

s of

hu

man

rig

hts

com

mis

sion

s o

n TB

and

hu

man

rig

hts

in t

he 1

0 co

unti

es

1. C

ondu

ct o

ne le

gal a

id c

linic

in e

ach

of t

he 1

0 co

unti

es e

very

yea

r.

2. Id

enti

fy h

uman

righ

ts o

rgan

isat

ions

an

d in

stit

utio

ns

that

ca

n pr

ovid

e le

gal

serv

ices

and

adv

ice

on a

dai

ly

basi

s fo

r w

alk

in c

lient

s

40%

1. C

ondu

ct o

ne le

gal a

id c

linic

in e

ach

of t

he 1

0 co

unti

es e

very

yea

r.

2. Id

enti

fy h

uman

righ

ts o

rgan

isat

ions

an

d in

stit

utio

ns th

at c

an p

rovi

de le

gal

serv

ices

and

adv

ice

on a

dai

ly b

asis

fo

r w

alk

in c

lient

s

60%

1.

Con

duct

on

e le

gal

aid

clin

ic

in

each

of

the

10 c

ount

ies

ever

y ye

ar.

2.

Iden

tify

hu

man

ri

ghts

or

gani

sati

ons

and

inst

itut

ions

tha

t ca

n pr

ovid

e le

gal

serv

ices

and

adv

ice

on a

dai

ly b

asis

for

w

alk

in c

lient

s

100%

4.3.9.3 Gender and H

uman Rights

Gen

der

and

Hum

an R

ight

s O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

(s)

Yea

r 1

Act

ivit

ies

Yr

1 Ta

rget

Yea

r 2

Act

ivit

ies

Yr

2 Ta

rget

Yea

r 3

Act

ivit

ies

Yr

3 Ta

rget

Yea

r 4

Act

ivit

ies

Yr

4 Ta

rget

Stra

tegi

c A

ppro

ach

3: T

rain

ing

of la

w m

aker

s, la

w e

nfor

cem

ent

agen

ts a

nd h

ealt

h ca

re w

orke

rs

Num

ber

of p

erso

nnel

tra

ined

Sens

itiz

atio

n of

he

alth

ca

re

wor

kers

, la

w

mak

ers,

la

w

enfo

rcem

ent

agen

ts

incl

udin

g po

lice

offi

cers

, an

d pr

ison

s of

fici

als,

ju

dici

al

offi

cers

, la

wye

rs,

pros

ecut

ion

offi

cers

, on

gen

der

and

hum

an r

ight

s in

Tu

berc

ulos

is,

Lepr

osy

and

lung

di

seas

es

Four

day

wor

ksho

ps

trai

ning

s o

n ge

nder

an

d hu

man

ri

ghts

is

sues

re

late

d to

TB

, le

pros

y an

d lu

ng

dise

ases

on

e in

ea

ch

of

the

47

coun

ties

, 30

part

icip

ants

per

cou

nty

1,41

0Fo

ur d

ay w

orks

hops

tr

aini

ngs

on

gend

er

and

hum

an

righ

ts

issu

es

rela

ted

to

TB,

lepr

osy

and

lung

di

seas

es

one

in

each

of

th

e 47

co

unti

es, 3

0 pa

rtic

ipan

ts p

er c

ount

y

1,41

0M

eeti

ngs

to

co

llect

fe

ed

back

fr

om

the

trai

ned

pers

onel

l a

nd e

valu

ate

the

impa

ct o

f th

e tr

aini

ng

Num

ber

of d

ialo

gue

fora

hel

d w

ith

stak

ehol

ders

Faci

litat

e di

alog

ues

disc

ussi

ons

and

nego

tiat

ions

am

ong

TB

serv

ice

prov

ider

s,

thos

e w

ho

acce

ss

serv

ices

an

d po

lice

to

addr

ess

law

en

forc

emen

t pr

acti

ces

that

im

pede

TB

pr

even

tion

, tr

eatm

ent,

car

e an

d su

ppor

t ef

fort

s

Con

duct

one

cou

nty

dial

ogue

for

um

in e

ach

of t

he 4

7 co

unty

wit

h th

e di

ffer

ent

stak

ehol

der

repr

esen

tati

ve

of t

hose

who

wer

e tr

aine

d

47C

ondu

ct o

ne c

ount

y di

alog

ue f

orum

in

eac

h of

the

10

coun

ty w

ith

the

diff

eren

t st

akeh

olde

r re

pres

enta

tive

of

tho

se w

ho w

ere

trai

ned

47C

ondu

ct o

ne c

ount

y di

alog

ue f

orum

in

each

of

the

10 c

ount

y w

ith

the

diff

eren

t st

akeh

olde

r re

pres

enta

tive

of

thos

e w

ho

wer

e tr

aine

d

47

Stra

tegi

c A

ppro

ach

4: F

orm

atio

n of

Inte

rsec

tora

l par

tner

ship

s be

twee

n th

e M

inis

try

of H

ealt

h an

d ot

her

part

s of

gov

ernm

ent

to e

mbe

d TB

con

cern

s

Num

ber

of s

take

hold

ers

and

part

ners

tr

aine

d to

add

ress

the

dis

pari

ties

in

gend

er a

nd h

uman

rig

hts

Sens

itiz

e re

leva

nt

gove

rnm

ent

inst

itut

ions

on

pa

rtne

rshi

ps

wit

h N

TLD

Pr

ogra

m

to

real

ize

hum

an r

ight

s an

d br

idge

gen

der

disp

arit

y in

TB

, Le

pros

y an

d lu

ng

dise

ases

an

d m

ains

trea

m

TB

polic

ies

in

nati

onal

co

nsid

erat

ions

Iden

tify

all

part

ners

and

sta

keho

lder

s bo

th

gove

rnm

ent

and

CSO

's

and

crea

te a

dat

a ba

se i

ndic

atin

g th

eir

resp

onsi

bilit

ies

in

mai

nstr

eam

ing

gend

er a

nd h

uman

rig

hts

in T

B le

p an

d lu

ng d

isea

se.

Thre

e da

y tr

aini

ng o

n TB

, Lep

and

LD

, ge

nder

an

d hu

man

rig

hts

citi

ng t

he

gend

er a

nd h

uman

rig

hts

issu

es o

f co

ncer

n an

d th

e po

ssib

le a

reas

of

inte

grat

ion

30Th

ree

day

foru

m

to

addr

ess

the

disp

arit

ies

in

gend

er

and

hum

an

righ

ts a

nd h

ow b

est

to m

ains

trea

m

both

into

the

ava

ilabl

e pr

ogra

ms

30Tw

o da

y se

nsit

izat

ion

foru

m t

o es

tabl

ish

wha

t pa

rtne

rs a

re d

oing

in

an e

ffor

t to

m

ains

trea

m

gend

er

and

hum

an

righ

ts

into

the

ir p

rogr

amm

es

4.3.9.4 Social protection

1. Situational Analysis

In 2011, Kenya published a National Social Protection Policy to build on the government’s commitment to poverty reduction as articulated in Vision 2030.

The National Social Protection Policy acknowledges that 46.7% of Kenyans (16.3 million people) live in poverty, unable to meet the cost of basic food. It also recognizes that “health risks that require a household to pay for medical treatment are of special concern to poor households.”

The National Social Protection Policy includes the following objectives1:

1. Protect individuals and households from the impact of adverse shocks to their consumption that is capable of pushing them into poverty or into deeper poverty

2. Support individuals and households to manage these shocks in ways that do not trap them in poverty by reducing their exclusion and strengthening their ability to graduate from social assistance and to become financially self-sufficient

3. Cushion workers and their dependents from the consequences of income-threatening risks, such as sickness, poor health, and injuries at work, as well as from the threat of poverty in their post-employment life

4. Promote key investments in human capital and physical assets by poor and non-poor households and individuals that will ensure their resilience in the medium-term, and that will break the intergenerational cycle of poverty. Promoting synergies and integration among social protection providers as well as positive interactions among stakeholders.

TB is more widespread among low income groups. The 2008/2009 Kenyan Demographic and Health Survey indicated that financial barriers to care were a primary cause of delayed care seeking. In particular, costs related to transportation and fee-based diagnostic tests, as well as lack of nutritional and financial support during the intensive phase of treatment was highlighted2. A study was undertaken in 2008 to estimate TB patients’ costs among 208 Nomadic Populations in Kitui North and Mutomo districts. It suggested that TB patients had a substantial burden of

_______________________________________________________________________________________________________________________________1 ibid, KNSPP2 Kenya NTLD Program Midterm Report 2014

Map 11: % of TB patients with BMI<18 among all notified cases

Map 12: % of malnourished (BMI<18) TB patients who receive caloric food

support

4.3.

9.4

Soci

al P

rote

ctio

n

129

direct (out of pocket: USD 55.8) and indirect (opportunity: USD 294.2) costs due to TB. It also showed that inability to work was a major cause of increased poverty, confirming an existence of a ‘medical poverty trap’ in the two districts. Other costing studies have shown similar barriers to care seeking and treatment compliance.

The NTLD Program estimates that over half of TB patients are malnourished at the onset of treatment, with 17% of those with TB being severely malnourished and a further 21% being moderately malnourished3. As illustrated in the maps, more than 50% of TB patients in some districts have BMI<18. Poor nutritional status is known to negatively impact treatment adherence and outcomes. Malnutrition weakens the immune system, and this increases the likelihood of latent TB turning into active TB. However, the majority of nutritional support programs active in Kenya do not prioritize food for TB patients. Furthermore, the majority of nutrition support programs target women and children, leaving out the male TB patients.

2. Strategic Directions

In May 2014, the World Health Assembly endorsed targets for TB control post-2015. This NSP will be one of the first to adopt the new global target of “no affected families facing catastrophic costs due to TB.”

To achieve this, a multi-pronged approach to extend social protections for TB patients will be sought. They will aim to reduce the direct and indirect costs of care seeking and treatment, while also addressing geographic, sociocultural and gender-related barriers to care.

3. Proposed Approaches

1. Promote policies and plans to ensure the inclusion of TB, leprosy and lung health patients in the current and emerging social protection schemes: Social protection schemes that address the indirect costs of illness and enable care seeking will be targeted for expansion to include TB and leprosy as qualifiers for benefits, such as: a) conditional cash transfers for care seeking, especially for women and children; b) transport voucher programs; and c) income generating activities.

a) Generate new, policy-relevant knowledge about the impact of social protection interventions on TB and leprosy control in settings characterized by different resources and epidemiological profiles; generate evidence for scale up in County Strategic Plans and other stakeholder plans

b) Develop a sub-plan and NTLD Program policy related to social protection, in collaboration with relevant stakeholders

c) Establish collaborative partnerships among those advancing the social protection agenda nationally and at county level; establish a mechanism (e.g. technical working group) for collaboration among social protection stakeholders

d) Advocate for County Governments to set aside resources for Social Protection for TB and leprosy patients.

2. Roll out nutritional support for TB and leprosy patients through existing platforms for food supporta) Targeted therapeutic feeding for all severely malnourished adults and children; both in and outpatients, as per WHO IMAM recommendations

b) Targeted supplementary feeding for all moderately malnourished adults and children meeting the criteria of BMI less than 18.5, as outpatients

c) Alternative feeding options to infants born of MDR-TB/PLHIV if and when mothers are unable to breastfeed exclusively on demand for the first six months

d) Multiple Micronutrient supplementation for all TB and leprosy cases during the intensive phase of treatment. It is important to note that the micro-nutrient survey conducted in 2003 showed that 76% of the Kenyan population were Vitamin A deficient. In arid areas, micro-nutrient supplementation is highly recommend as part of the nutrition policy

e) Promote TB and leprosy as automatic eligibility criteria for inclusion in food safety nets

f) Scale-up the use of nutrition education and screening as an integral component of community-based care and household visits

_______________________________________________________________________________________________________________________________

3 ibid, Midterm Report

4.3.9.4 Social Protection

130

_______________________________________________________________________________________________________________________________5 National Strategic Plan for Tuberculosis, Leprosy and Lung Health 2015-2018

g) Build capacity of health workers to improve on quality of nutrition assessment, counseling, care and support of all patients

h) Increase availability and access to nutrition assessment, counseling, and support (NACS) at community and facility levels.

3. Promote policies to reduce the direct costs of TB diagnosis and treatment.

a) Ensure the mandatory inclusion of TB benefits within health insurance packages, both public and private, to help mitigate the direct expenses associated with TB diagnosis and care5

b) Eliminate diagnostic fees for children

4. Promote a legal framework to protect TB patients in the workplace from discrimination and the fear/reality of lost income.

4.3.

9.4

Soci

al P

rote

ctio

n

131

4.3.9.4 Social Protection

Soci

al P

rote

ctio

n O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

sY

ear

1 A

ctiv

itie

sY

r 1

Targ

etY

ear

2 A

ctiv

itie

sY

r 2

Targ

etY

ear

3 A

ctiv

itie

sY

r 3

Targ

etY

ear

4 A

ctiv

itie

sY

r 4

Targ

et

Stra

tegi

c A

ppro

ach

1: P

olic

y de

velo

pmen

t fo

r so

cial

pro

tect

ion:

ens

urin

g th

e in

clus

ion

of T

B an

d le

pros

y pa

tien

ts a

mon

g th

e be

nefi

ciar

ies

of s

ocia

l pro

tect

ion

sche

mes

Num

ber

of n

atio

nal

polic

y do

cum

ents

and

an

nual

pl

ans

(n

atio

nal)

deve

lope

d an

d di

ssem

inat

ed o

n so

cial

pro

tect

ion

of T

B pa

tien

ts

Inte

grat

e an

d co

ordi

nate

so

cial

pr

otec

tion

pr

ogra

mm

es

and

prog

ram

min

g fo

r TB

& l

epro

sy i

n th

e co

untr

y

Hol

d st

eeri

ng c

omm

itte

e an

d TW

G m

eeti

ngs

1H

old

quat

erly

TW

G m

eeti

ngs

Con

duct

2 s

take

hold

ers/

dia

logu

e/se

nsit

izat

ion

mee

ting

s, T

A

2H

old

quat

erly

TW

G m

eeti

ngs

Con

duct

2 s

take

hold

ers/

dia

logu

e/se

nsit

izat

ion

mee

ting

s

2H

old

quat

erly

TW

G m

eeti

ngs.

Con

duct

2

stak

ehol

ders

/dia

logu

e/se

nsit

izat

ion

mee

ting

s

n/a

Prop

orti

on o

f ta

rget

ed s

take

hold

ers

that

ha

ve b

een

brie

fed

on n

eed

to i

nclu

de T

B in

soc

ial

prot

ecti

on p

latf

orm

s; a

nd p

lans

dr

afte

d

Hol

d

nati

onal

TB

so

cial

pr

otec

tion

st

akeh

olde

r m

eeti

ngs

25H

old

bian

nual

so

cial

pr

otec

tion

st

akeh

olde

r m

eeti

ngs

50H

old

bian

nual

so

cial

pr

otec

tion

st

akeh

olde

r m

eeti

ngs

75H

old

bian

nual

so

cial

pr

otec

tion

st

akeh

olde

r m

eeti

ngs

100

Prop

orti

on o

f co

unti

es b

rief

ed o

n ne

ed t

o in

clud

e TB

in s

ocia

l pro

tect

ion

plat

form

s5

Hol

d bi

annu

al

TB

soci

al

prot

ecti

on s

take

hold

er m

eeti

ng in

15

cou

ntie

s

33H

old

bian

nual

TB

soci

al p

rote

ctio

n st

akeh

olde

r m

eeti

ng in

15

coun

ties

66H

old

bian

nual

TB

soci

al p

rote

ctio

n st

akeh

olde

r m

eeti

ng in

15

coun

ties

100

Prop

orti

on o

f co

unti

es h

avin

g in

vent

orie

s of

soc

ial

prot

ecti

on r

esou

rces

, an

d co

unty

pl

ans

deve

lope

d fo

r su

ppor

t to

TB

pati

ents

Prin

t TB

3,

600

soci

al

prot

ecti

on p

olic

y do

cum

ents

Hol

d 4

TB

soci

al p

rote

ctio

n po

licy

deve

lopm

ent

wor

ksho

ps.

10D

istr

ibut

e TB

soci

al

prot

ecti

on

polic

y do

cum

ents

to

47 c

ount

ies

25H

old

47

Cou

nty

di

ssem

inat

ion

mee

etin

gs

for

the

TB

so

cial

pr

rote

ctio

n po

licy

docu

men

t

25

Num

ber

of

coun

ties

w

ith

TB

soci

al

prot

ecti

on p

olic

y do

cum

ents

ava

ilabl

eTe

chni

cal

assi

stan

ce

to

15

coun

ties

for

soc

ial

prot

ecti

on

plan

ning

15Te

chni

cal

assi

stan

ce

to

15

coun

ties

fo

r so

cial

pr

otec

tion

pl

anni

ng

30H

old

a na

tion

al

diss

emin

atio

n m

eeti

ng f

or t

he T

B so

cial

pro

tect

ion

polic

y do

cum

ent,

less

ons

lear

ned

47Te

chni

cal

assi

stan

ce t

o 15

cou

ntie

s fo

r so

cial

pro

tect

ion

plan

ning

47

Reim

burs

emen

t le

vels

for

TB

diag

nosi

s an

d ca

re in

hea

lth

insu

ranc

e qu

anti

fied

Dev

elop

co

st

reim

burs

emen

t sc

hedu

le f

or T

B di

agno

sis

and

care

wit

hin

heal

th i

nsur

ance

sc

hem

es (t

echn

ical

ass

ista

nce)

1

Prop

orti

on

of

heal

th

insu

ranc

e po

licie

s (p

ublic

and

pri

vate

) th

at h

ave

man

dato

ry

cove

rage

of

TB p

atie

nts

Hol

d ad

voca

cy m

eeti

ngs

for

TB

soci

al p

rote

ctio

n w

ith

rele

veva

nt

agen

cies

e.

g N

atio

nal

Hos

pita

l In

sura

nce

Fund

5H

old

10 a

dvoc

acy

mee

ting

s fo

r TB

so

cial

pr

otec

tion

w

ith

rele

veva

nt

agen

cies

e.

g N

atio

nal

Hos

pita

l In

sura

nce

Fund

20H

old

10 a

dvoc

acy

mee

ting

s fo

r TB

so

cial

pr

otec

tion

w

ith

rele

veva

nt

agen

cies

e.

g N

atio

nal

Hos

pita

l In

sura

nce

Fund

50

Prop

orti

on o

f TB

pati

ents

cov

ered

by

heal

th

insu

ranc

e5

2050

Stra

tegi

c A

ppro

ach

2: R

oll o

ut n

utri

tion

al s

uppo

rt f

or T

B an

d le

pros

y pa

tien

ts t

hrou

gh e

xist

ing

plat

form

s fo

r fo

od s

uppo

rt

Prop

orti

on o

f el

igib

le T

B pa

tien

ts r

ecei

ving

nu

trit

ion

supp

ort

Cap

acit

y bu

ildin

g am

ong

heal

th

care

wor

kers

for

nut

riti

on n

eeds

am

ong

TB p

atie

nts

Trai

n 18

0 he

alth

ca

re

wor

kers

on

TB n

utri

tion

fro

m

coun

ties

w

ith

high

est

rate

s of

m

alnu

trit

ion

amon

g TB

pa

tien

ts

30Tr

ain

180

heal

th c

are

wor

kers

on

TB n

utri

tion

fro

m c

ount

ies

wit

h hi

ghes

t ra

tes

of

mal

nutr

itio

n am

ong

TB p

atie

nts

50Tr

ain

180

heal

th c

are

wor

kers

on

TB

nutr

itio

n fr

om c

ount

ies

wit

h hi

ghes

t ra

tes

of

mal

nutr

itio

n am

ong

TB

pati

ents

80Tr

ain

180

heal

th c

are

wor

kers

on

TB

nutr

itio

n fr

om c

ount

ies

wit

h hi

ghes

t ra

tes

of

mal

nutr

itio

n am

ong

TB

pati

ents

80

Tool

s de

velo

pmen

t fo

r he

alth

w

orke

rs a

nd C

HEW

s on

nut

riti

onal

as

sess

men

t an

d nu

trit

iona

l sup

port

Dev

elop

on-

the-

job

tool

s fo

r he

alth

fac

iliti

es a

nd C

HEW

s D

isse

min

atio

n to

all

coun

ties

Dis

sem

inat

ion

to a

ll co

unti

es

Con

duct

nati

onal

te

chni

cal

assi

stan

ce

(TA

)

on

TB

nutr

itio

n,

targ

etin

g co

unti

es

wit

h w

orst

m

alnu

trit

ion

amon

g TB

pat

ient

s on

tr

eatm

ent.

Con

duct

na

tion

al

te

chni

cal

assi

stan

ce (T

A)

on T

B nu

trit

ion

tart

egtt

ing

coun

ties

w

ith

wor

st m

alnu

trit

ion

amon

g TB

pa

tien

ts o

n tr

eatm

ent.

Con

duct

tech

nica

l as

sist

ance

(T

A)

on

TB n

utri

tion

tar

tegt

ting

co

unti

es w

ith

wor

st m

alnu

trit

ion

amon

g TB

pat

ient

s on

tre

atm

ent.

Con

duct

te

chni

cal

assi

stan

ce (

TA)

on T

B nu

trit

ion

tart

egtt

ing

coun

ties

w

ith

wor

st m

alnu

trit

ion

amon

g TB

pa

tien

ts o

n tr

eatm

ent.

Con

duct

te

chni

cal

assi

stan

ce (

TA)

on T

B nu

trit

ion

tart

egtt

ing

coun

ties

w

ith

wor

st m

alnu

trit

ion

amon

g TB

pa

tien

ts o

n tr

eatm

ent.

Dev

elop

po

siti

on

pape

r an

d co

nduc

t ad

voca

cy f

or i

nclu

sion

of

TB p

atie

nts

by o

ther

foo

d su

ppor

t pr

ovid

ers

Dev

elop

po

siti

on

pape

r on

re

leva

nce

of

food

su

ppor

t fo

r el

igib

le

TB p

atie

nts

(and

fa

mili

es)

Targ

eted

adv

ocac

y fo

r inc

lusi

on o

f TB

pat

ient

s in

foo

d pr

ogra

mm

esN

atio

nal p

olic

y dr

afti

ng: T

B pa

tien

ts

auto

mat

ical

ly e

ligib

le f

or f

ood

Targ

eted

adv

ocac

y fo

r in

clus

ion

of

TB p

atie

nts

in f

ood

prog

ram

mes

Soci

al P

rote

ctio

n O

pera

tion

al P

lan

Out

put

Indi

cato

r(s)

Inte

rven

tion

sY

ear

1 A

ctiv

itie

sY

r 1

Targ

etY

ear

2 A

ctiv

itie

sY

r 2

Targ

etY

ear

3 A

ctiv

itie

sY

r 3

Targ

etY

ear

4 A

ctiv

itie

sY

r 4

Targ

et

Proc

ure

ther

apeu

tic

and

supp

lem

enta

ry f

eeds

for

elig

ible

TB

pati

ents

not

cov

ered

by

othe

r fo

od

supp

ort

prog

ram

s

Proc

ure

ther

apeu

tic

and

supp

lem

enta

ry

feed

s fo

r 50

,000

TB

apti

ents

Proc

ure

ther

apeu

tic

and

supp

lem

enta

ry f

eeds

for

50,

000

TB a

ptie

nts

Proc

ure

Nut

riti

onal

sup

plem

ents

for

30

,000

M

oder

atet

ly

Mal

nour

ishe

d TB

Pat

ient

s

Proc

ure

Nut

riti

onal

sup

plem

ents

for

30

,000

M

oder

atet

ly

Mal

nour

ishe

d TB

Pat

ient

s

Proc

ure

ther

apeu

tic

feed

s fo

r 20

,000

Se

vere

ly

Mal

nour

ishe

d TB

Pa

tien

ts

Proc

ure

ther

apeu

tic

feed

s fo

r 20

,000

Se

vere

ly M

alno

uris

hed

TB P

atie

nts

Prop

orti

on

of

elig

ible

br

east

feed

ing

mot

hers

wit

h M

DR-

TB g

iven

the

opt

ion

of

alte

rnat

ive

feed

ing

for

infa

nts

Prov

ide

alte

rnat

ive

feed

ing

opti

ons

to i

nfan

ts b

orn

of M

DR-

TB i

f an

d w

hen

mot

hers

ar

e un

able

to

br

east

feed

exc

lusi

vely

on

dem

and

for

the

firs

t si

x m

onth

s

Prov

ide

alte

rnat

ive

feed

ing

7 M

DR-

TB

brea

stfe

edin

g m

othe

rs

20Pr

ovid

e al

tern

ativ

e fe

edin

g 7

MD

R-TB

bre

astf

eedi

ng m

othe

rs50

Prov

ide

alte

rnat

ive

feed

ing

7 M

DR-

TB b

reas

tfee

ding

mot

hers

75Pr

ovid

e al

tern

ativ

e fe

edin

g 7

MD

R-TB

bre

astf

eedi

ng m

othe

rs10

0

Stra

tegi

c A

ppro

ach

3: E

stab

lish

colla

bora

tive

par

tner

ship

s am

ong

thos

e ad

vanc

ing

the

soci

al p

rote

ctio

n ag

enda

at

nati

onal

and

cou

nty

leve

ls

Prop

orti

on

of

elig

ible

TB

pa

tien

ts

part

icip

atin

g in

IGA

sSu

ppor

t th

e in

corp

orat

ion

of

TB

pati

ents

in

to

exis

ting

/em

ergi

ng

inco

me

gene

rati

ng a

ctiv

itie

s (IG

As)

Inve

ntor

y IG

As

in

coun

try

and

docu

men

t ac

cess

by

TB

pati

ents

Incl

ude

TB p

atie

nts

in I

GA

s i

n 15

co

unti

es

mos

t af

fect

ed

by

mal

nutr

itio

n am

ong

TB p

atie

nts

15In

clud

e TB

pa

tien

ts

in

IGA

s

in

15

coun

ties

m

ost

affe

cted

by

m

alnu

trit

ion

amon

g TB

pat

ient

s

25In

clud

e TB

pa

tien

ts

in

IGA

s

in

17

coun

ties

m

ost

affe

cted

by

m

alnu

trit

ion

amon

g TB

pat

ient

s

30

Prop

orti

on o

f el

igib

le T

B pa

tien

ts r

ecei

ving

su

ppor

t th

roug

h m

onth

ly c

ash

tran

sfer

Supp

ort t

he in

clus

ion

of T

B pa

tien

ts

in

cond

itio

nal

cash

tr

ansf

er

sche

mes

Inve

ntor

y co

ndit

iona

l ca

sh

tran

sfer

pro

gram

s an

d ac

cess

by

TB

pati

ents

Prom

ote

incl

usio

n of

TB

pati

ents

in

co

ndit

iona

l ca

sh

tran

sfer

pr

ogra

ms

(sta

keho

lder

m

eeti

ngs

and

targ

eted

ad

voca

cy

in

10

coun

ties

)

10Pr

omot

e in

clus

ion

of T

B pa

tien

ts i

n co

ndit

iona

l ca

sh t

rans

fer

prog

ram

s (s

take

hold

er m

eeti

ngs

and

targ

eted

ad

voca

cy in

15

coun

ties

)

25Pr

omot

e in

clus

ion

of T

B pa

tien

ts i

n co

ndit

iona

l ca

sh t

rans

fer

prog

ram

s (s

take

hold

er m

eeti

ngs

and

targ

eted

ad

voca

cy in

20

coun

ties

)

50

Prop

orti

on o

f el

igib

le T

B an

d pr

esum

ptiv

e TB

cas

es r

ecei

ving

tra

nspo

rt v

ouch

ers

for

diag

nost

ic a

nd c

are

serv

ices

Supp

ort t

he in

clus

ion

of T

B pa

tien

ts

in t

rans

port

sch

emes

Inve

ntor

y tr

ansp

ort

reim

bu

rse

me

nt/

vo

uc

he

r pr

ogra

ms

and

acce

ss

by

TB

pati

ents

Prom

ote

incl

usio

n of

TB

pati

ents

in

tr

ansp

ort

vouc

her

prog

ram

s (s

take

hold

er

mee

ting

s an

d ta

rget

ed a

dvoc

acy

in 1

0 co

unti

es)

10Pr

omot

e in

clus

ion

of

TB

pati

ents

in

tr

ansp

ort

vouc

her

prog

ram

s (s

take

hold

er m

eeti

ngs

and

targ

eted

ad

voca

cy in

10

coun

ties

)

25Pr

omot

e in

clus

ion

of

TB

pati

ents

in

tr

ansp

ort

vouc

her

prog

ram

s (s

take

hold

er m

eeti

ngs

and

targ

eted

ad

voca

cy in

10

coun

ties

)

50

Esta

blis

h co

sts

incu

rred

by

pa

tien

ts

in

acce

ssin

g TB

dia

gnos

is a

nd t

reat

men

tRe

sarc

h on

co

sts

incu

rred

in

ac

cess

ing

Tb m

anag

emen

tRe

sear

ch

on

cost

s in

curr

ed

in

acce

ssin

g TB

man

agem

ent

Resa

rch

on

cost

s in

curr

ed

in

acce

ssin

g Tb

man

agem

ent

4.3.

9.4

Soci

al P

rote

ctio

n

4.4.1 Practical Approach to Lung H

ealth

4.4. Halt/Reverse Non–Communicable Diseases

4.4.1. Expand utilization of practical approach to lung health

1. Situational Analysis

In Kenya, respiratory disease conditions form 25% of outpatient morbidity1. Pneumonia accounts for 9% of hospital admissions, while tuberculosis contributes 2%. Summary data from public health facilities categorize respiratory tract conditions into pneumonia and tuberculosis, and ‘others.’ Among the causes of mortality in the Kenya population, pneumonia contributes 12% and tuberculosis 5.5%.

There are no population-based studies in Kenya that have examined the prevalence of asthma among all age groups or chronic obstructive pulmonary disease (COPD). These would be important to provide a baseline to measure the effects of implementing the Practical Approach to Lung Health (PAL) strategy. Kenya has participated in the International Studies of Asthma and Allergic Disease in Childhood (ISAAC) Phase 1 and 3 at two sites: Nairobi and Eldoret. The prevalence of wheeze in the past 12 months among 13-14 year old children in the ISAAC Phase 1 study carried out in 1995 was 17.1% and 10.4 % in Nairobi and Eldoret respectively2. In the ISAAC Phase 3 study of 2000, this prevalence had increased to 18% and 13.8 % in Nairobi and Eldoret respectively3. Based on the results of the ISAAC studies, it is estimated that about 10% of the Kenyan population, or nearly 4 million people, have asthma.

PAL aims at improving the quality of care for patients with respiratory conditions. The focus is patients treated in primary health settings with cough and are not diagnosed with tuberculosis.

The NTLD Program and partners have adopted the PAL strategy to address lung health issues comprehensively and to improve the case management of TB, especially at the primary health care level. The PAL strategy is also expected to contribute to health system strengthening for TB and lung health. The Kenyan PAL strategy focuses on the following diseases: TB, asthma, COPD, acute respiratory illness, and TB/HIV.

PAL was initiated in 2011 with the formation of a national task force comprising of members from the TB program, KAPTLD, KEMRI, WHO and community representatives. A step-wise approach to PAL implementation was adopted as outlined below:

a) Obtaining political commitment

b) Preliminary assessment aimed at determiningi. Potential challenges for PAL implementation in Kenyaii. Opportunities for PAL implementationiii. The country’s capacity to implement PAL.

c) Development and adoption of guidelines and M&E tools

d) Adoption/review of existing training material and development of a core group of trainers and researchers at the national and county level

e) Piloting PAL implementation in one county

f) Evaluation of the pilot at 6 months, followed by phased scale-up to other counties.

Several challenges hindered this process and much of what was planned was not done. The main challenge was limited funds. To date, the following has been achieved:

134

a) A national focal person for PAL implementation was identified and two trainers were trained by the South African PALSA program, the pioneer in Africa on PAL implementation

b) PAL guidelines, training materials and educational materials were adapted from the PALSA program

c) Asthma registers and patient management cards were developed and printed

The following gaps currently exist in PAL implementation:

a) An evaluation of the first phase of PAL implementation has not been conducted and it is difficult to tell if the trained TB distrct managers cascaded the training to primary health care workers

b) The national team has not been sufficiently trained on PAL to support the roll-out of the strategy

c) The PAL TWG has not been consistent in convening to provide strategic direction to implementers

d) There is an inadequate supply of essential equipment and commodities to support diagnosis and treatment at the health facilities

e) There is no defined M&E plan for the PAL strategy.

Most of the existing processes need to be sustained and improved to enhance detection and efficient management of the chronic lung illnesses in all health facilities. In addition, there are opportunities for improvement and scale-up of the PAL strategy. They include:

a) Ensuring political commitment among the county governments and stakeholders

b) Advocating for resource allocation for implementation of PAL from the county and national governments, private sector and the donor community

c) Mapping of partnerships and resources from organisations and institutions with common interests for leveraging

d) Dissemination of PAL policy documents and guidelines

e) Establishing coordination mechanisms for PAL implementation at the county level, while strengthening the exisiting structures at national level

2. Strategic Directions 2015-2018

For PAL implementation to be effective in Kenya, three main areas need to be prioritized, namely,

a) Strengthen coordination mechanisms at the national level and establish coordination structures at the county levels b) Establish the burden of respiratory diseases in Kenya and develop a robust respiratory disease surveillance systemc) Assess the impact of the first phase of PALd) Scale-up PAL implementation, including procurement of necessary equipment and medicines, capacity building of

health care workers and strengthening referral systems for lung health.

3. Proposed Approaches

Strengthen coordination mechanisms at the national level and establish coordination structures at the County levels for the implementation of PAL. The following is proposed:a) Revamp the national PAL technical working group (TWG) and ensure regular quarterly meetingsb) Promote county forums with county management teams and stakeholders to establish political commitment for the

management of respiratory conditions through the PAL strategy in the countiesc) Advocate for the formation of county TWGs on PALd) Mapping of partnerships and resources from organisations and institutions with common interests for leveraginge) Provide technical assistance through identified Centers of Excellence - either public or private.

Establish the burden of respiratory diseases in Kenya and develop a robust respiratory disease surveillance systema) Conduct baseline population based survey on the burden of lung diseases defined in the Kenya PAL strategyb) Complete assessment of the impact of the first phase of PAL implementation

_______________________________________________________________________________________________________________________________1 Ministry of Health report, 2009, Kenya2 The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). Eur Respir J 1998; 12: 315 – 335. 3 Ait-Khaled N, Odhiambo J, Pearce N, Prevalence of symptoms of asthma, rhinitis and eczema in 13- to 14-year-old children in Africa: the International Study of Asthma and Allergies in Childhood Phase III. Allergy. 2007 Mar; 62(3): 247-58.

4.4.

1 Pr

acti

cal A

ppro

ach

to L

ung

Hea

lth

135

4.4.1 Practical Approach to Lung H

ealth

c) Introduce cough registers at the out-patient departments (OPDs) to enable tracking of all patients/clients with respiratory illnesses

d) Establish a surveillance system on PAL i. Develop an M&E plan for PALii. Disseminate recording and reporting tools iii. Include PAL indicators in the TIBU system and streamline the reporting system with the other disease areas.

Scale-up PAL implementation, including ensuring availability of necessary equipment and medicines, capacity building of health care workers and strengthening referral systems for lung health.

a) Capacity building of health care workers through:i. Training TOTs at the National and county levelii. Facilitating the TOTs to conduct regular health facility based on-the-job training iii. Recruiting a team of respiratory resource persons to conduct ongoing mentorship to the trained health care providersiv. Evaluation, retaining, mentoring and offering continuous technical assistance and CMEs in already established model

unitsv. Developing, printing and disseminating job aids, diagnostic algorithms and IEC materials for targeting community,

workplaces, health care providers informing them of triggers including biomass fuels and tobacco smokingvi. Developing an e-learning package for respiratory diseases with certification of health care providersvii. Sensitize county pharmacists on PAL commodities

b) Ensure availability of commodities required for PAL implementation in all the Counties by advocating for the inclusion of the following medicines in the essential drug package of all PHC facilities: antibiotics for community acquired pneumonia (CAP) and acute respiratory infections (ARIs), inhaled corticosteroids, inhaled bronchodilators, analgesics, antitussives and anticholinergics.

c) Ensure availability (or access) to diagnostic facilities and essential equipment for management of common lung conditions. These include:i. Radiological services: X-Ray equipment and training in radiology techniques, interpretation, quality control of chest

radiographs, radiation protection etc.ii. Essential medical equipment: Oxygen sources, pulse oximeters, nebulizers, peak flow meters with disposable mouth

pieces, spirometers and spacers

d) Develop model lung health units in the 47 counties to be used for mentorship and engage previoulsy trained TOTs. The health units will have a minimum package as outlined below:

• Trained personnel on PAL diseases• Equipment e.g. at least a peak flow meters with or without a spirometer, nebulizers, mouth pieces, spacers• Commodities: PAL drugs (Relievers and controllers)• M&E tools - Registers, Patient management cards, Appointment cards, Supervision tools, IEC materials

The following counties will be targeted for establishing these lung units in Year 1: Nairobi (Mbagathi and Mama Lucy Kibaki hospitals), Machakos county hospital, Nyeri county hospital, Kericho County Hospital, Coast County Referral Hospital, Kakamega County Hospital, Kisumu County Hospital, Kisii County Hospital, Garissa County Hospital, Isiolo County Hospital and Kitale County Hospital. These are former provincial and level 5 hospitals that have medical outpatient clinics (MOPC) running.

The lung health clinics will be integrated within the MOPCs on selected specific days. Lessons learnt from the established model clinics of year 1, will support the creation of other model lung health units in other counties on phased out implementation manner to cover all counties. We anticipate that on a yearly basis, additional 12 lung units will be established to increase county coverage.

e) Communication and advocacy strategy for PALi. Develop a communication strategy for lung health targeting the community, the patients and the health care workersii. Develop educational messages for respiratory patients and their familiesiii. Advocate for resource allocation for implementation of PAL from the government, private sector and the donor

communityiv. Advocate for multisectoral involvement in lung health in Kenya.

Ministry of Education1. Include PAL guideline in the training curricula for medical schools, public health schools 2. Introduction of PAL messages in primary and secondary schools

136

Ministries of Labor and Industry

1. Regulations for prevention of occupational related lung diseases e.g. cement factories, mining etc.2. Care of respiratory (communicable diseases) in congregate settings e.g. orphanages, prisons, street families

etc.

Disaster Preparedness and Management Units

1. Anticipation and planning for respiratory disease outbreaks in camps following disasters or population displacements

2. Planning for management of those with chronic illnesses in camps of displaced people.

Research Institutions

Non-Communicable Disease Department

Contribution to NSP Impacts Outcomes

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

• Increase case notification of new TB cases to 85% of estimated prevalence

Impact 5: Reduce morbidity due to chronic lung diseases • Reduce the average number of annual acute episodes for children with asthma by 15% in areas with established asthma clinics

• Increase to 80% the proportion of controlled asthma patients

Table 15: Impact and Outcome Indicators for PAL

4.4.

1 Pr

acti

cal A

ppro

ach

to L

ung

Hea

lth

137

4.4.1 Practical Approach to Lung H

ealth

Lung

Hea

lth

Ope

rati

onal

Pla

nO

utpu

t In

dica

tor(

s)In

terv

enti

on(s

)Y

ear

1 A

ctiv

itie

sY

r 1

Targ

etY

ear

2 A

ctiv

itie

sY

r 2

Targ

etY

ear

3 A

ctiv

itie

sY

r 3

Targ

etY

ear

4 A

ctiv

itie

sY

r 4

Targ

et

Stra

tegi

c A

ppro

ach

1: S

tren

gthe

n co

ordi

nati

on m

echa

nism

s at

the

nat

iona

l lev

el a

nd e

stab

lish

coor

dina

tion

str

uctu

res

at t

he C

ount

y le

vels

for

impl

emen

tati

on o

f PA

L

Num

ber

of P

AL

TWG

mee

ting

s he

ldRe

vam

p th

e N

atio

nal

PAL

tech

nica

l w

orki

ng g

roup

(TW

G)

Hol

d qu

arte

rly

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m

eeti

ngs

2H

old

quar

terl

y TW

G m

eeti

ngs

4H

old

quar

terl

y TW

G m

eeti

ngs

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old

quar

terl

y TW

G m

eeti

ngs

4

Num

ber

of

mul

tise

ctor

al

cons

ulta

tive

br

eakf

ast

mee

ting

s he

ld A

dvoc

ate

for m

ulti

sect

oral

invo

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ent

in lu

ng h

ealt

h in

Ken

yaH

old

mul

tise

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al

cons

ulta

tive

br

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ast

mee

ting

s

2H

old

mul

tise

ctor

al c

onsu

ltat

ive

brea

kfas

t m

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ng1

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d m

ulti

sect

oral

co

nsul

tati

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brea

kfas

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ng

1H

old

mul

tise

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al

cons

ulta

tive

br

eakf

ast

mee

ting

1

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orti

on o

f C

ount

ies

allo

cati

ng f

unds

for

PA

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plem

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tion

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y fo

rum

s to

m

obili

ze

polit

ical

co

mm

itm

ent

and

reso

urce

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ilisa

tion

Hol

d m

eeti

ng w

ith

coun

ty

heal

th

man

agem

ent

team

s (1

2)

25%

Hol

d m

eeti

ng

wit

h co

unty

he

alth

man

agem

ent

team

s (4

7)50

%H

old

mee

ting

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ith

coun

ty

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th

man

agem

ent

team

s (4

7)60

%H

old

mee

ting

w

ith

coun

ty

heal

th

man

agem

ent

team

s (4

7)75

%

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sult

ativ

e fo

rum

s w

ith

coun

ty s

take

hold

ers

1C

onsu

ltat

ive

foru

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h co

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sult

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e fo

rum

s w

ith

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ty

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on o

f C

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wit

h fu

ncti

onal

TW

Gs

Prov

ide

tech

nica

l as

sist

ance

to

coun

ty

TWG

s.Pr

ovid

e te

chni

cal

assi

stan

ce

to

coun

ty

TWG

s (1

2)

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tech

nica

l as

sist

ance

to

coun

ty T

WG

s (4

7)50

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e te

chni

cal

assi

stan

ce

to

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ty T

WG

s (4

7)

75%

Prov

ide

tech

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l as

sist

ance

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unty

TW

Gs

(47)

75%

prop

orti

on

of p

artn

ers

map

ped

part

icip

atin

g in

lung

hea

lth

Map

ping

of

part

ners

hips

for

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LH

old

a se

nsit

isat

ion

mee

ting

(n

atio

nal

brea

kfas

t m

eeti

ng)

for

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ping

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tner

s

20%

Hol

d a

sens

itis

atio

n m

eeti

ng

(nat

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l bre

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ng) f

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map

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par

tner

s

40%

Hol

d a

sens

itis

atio

n m

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ng

(nat

iona

l br

eakf

ast

mee

ting

) fo

r m

appi

ng p

artn

ers

60%

Hol

d a

sens

itis

atio

n m

eeti

ng (n

atio

nal

brea

kfas

t m

eeti

ng)

for

map

ping

pa

rtne

rs

75%

Stra

tegi

c A

ppro

ach

2: E

stab

lish

the

burd

en o

f re

spir

ator

y di

seas

es in

Ken

ya a

nd d

evel

op a

rob

ust

resp

irat

ory

dise

ase

surv

eilla

nce

syst

em

Nat

iona

l ba

selin

e da

ta

of b

urde

n of

lun

g di

seas

es a

vaila

ble

Con

duct

ba

selin

e po

pula

tion

ba

sed

surv

ey o

n th

e bu

rden

of

lung

dis

ease

sC

ondu

ct b

asel

ine

stud

yC

ondu

ct B

asel

ine

stud

y1

Nat

iona

l pla

n de

velo

ped

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ss b

urde

n of

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ng d

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ses

Base

d on

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sult

s of

ba

selin

e su

rvey

, co

nven

e TW

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and

deve

lop

mul

ti-

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oral

pla

n

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ehol

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ting

s to

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sem

inat

e re

sult

s of

ba

selin

e su

rvey

; dr

aft

nati

onal

pl

an

wit

h C

ount

y in

volv

emen

t

2N

atio

nal

plan

fo

r ad

dres

sing

lu

ng

dise

ases

in

corp

orat

ed

into

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ount

y he

alth

pla

ns

1

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iona

l M

&E

plan

s an

d to

ols

for

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surv

eilla

nce

avai

labl

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op a

n M

&E

plan

and

too

ls f

or P

AL

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lize

deve

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ent

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and

pl

an

1

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ber

of o

f M

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ls a

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lans

for

PA

L pr

inte

dPr

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t M

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s (f

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s,

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ent

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d ap

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tool

s D

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s re

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ugh

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h TI

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ugh

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tegi

c A

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ach

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cale

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impl

emen

tati

on, i

nclu

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g av

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bilit

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nec

essa

ry e

quip

men

t an

d m

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, cap

acit

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g of

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and

stre

ngth

enin

g re

ferr

al s

yste

ms

for

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lth

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ber

of N

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nal T

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tra

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n 25

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n PA

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iona

l le

vel

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n na

tion

al T

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on P

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25

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ber

of c

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y TO

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rain

ed o

n PA

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ain

150

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at

coun

ty l

evel

(3

per

coun

ty) o

n PA

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ain

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nty

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on

PAL

150

00

0

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ber

of C

ount

y H

CW

s tr

aine

d on

PA

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ct P

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trai

ning

s in

the

cou

ntie

s 25

HC

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coun

ty t

rain

ed

in 1

2 co

unti

es30

025

HC

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cou

nty

trai

ned

in 3

7 co

unti

es87

525

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s/co

unty

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aine

d in

47

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ties

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100

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f co

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ith

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mat

eria

lsD

evel

op jo

b ai

ds ,

diag

nost

ic a

lgor

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s an

d IE

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ater

ials

for

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LD

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ster

s,

flye

rs

and

diag

nost

ics

algo

rith

ms

for

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t PA

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ds ,

diag

nost

ic a

lgor

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s an

d IE

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t 5,

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50

,000

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, 50

0 di

agno

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gori

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t 10

,000

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ters

, 10

0,00

0 fl

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, 1,

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ics

algo

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t 10

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, 100

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1,

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gnos

tics

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int

10,0

00 p

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rs,

100,

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iagn

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cs a

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Lung

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lth

Ope

rati

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Pla

nO

utpu

t In

dica

tor(

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terv

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on(s

)Y

ear

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ctiv

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r 1

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etY

ear

2 A

ctiv

itie

sY

r 2

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etY

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3 A

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itie

sY

r 3

Targ

etY

ear

4 A

ctiv

itie

sY

r 4

Targ

et

Dis

trib

ute

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job

aids

, di

agno

stic

al

gori

thm

s an

d IE

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ater

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trib

ute

5,00

0 po

ster

s,

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00

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rs,

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diag

nost

ics

algo

rith

ms.

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trib

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4.5.1 IPC, Contact Tracing and IPT

4.5. Minimize Risk Factor Exposure

4.5.1. Prevent transmission and disease: infection prevention and control, contact tracing and Isoniazid preventive therapy

1. Situational Analysis

a) Infection Prevention and Control

Transmission of TB in congregate and health care settings remains a major problem in Kenya. Most of the health facilities in the country were designed to serve smaller populations than they currently handle, and without much attention to TB prevention. It is estimated that one untreated infectious TB patient will infect 10 people each year. Thus, the high volume of infectious TB patients visiting the facilities makes them a fertile transmission setting.

Kenya developed TB infection prevention and control guidelines in 2009, followed by sensitization and training of high volume facilities. However, the country still lacks data on the extent of spread of TB in health care and other congregate settings. Moreover, TB surveillance is not specifically done for these settings, save for prisons. Health care workers suffer more than three times the national TB burden. Studies conducted in Eastern and Nairobi regions in 2012 and 2013 revealed a TB case notification rate of greater than 800/100,000 population1.There is thus an urgent need to redefine and address national IPC priorities.

Structured TB Infection prevention and control (IPC) implementation commenced in 2009 with the establishment of national coordination at NTLD Program and identification of a focal person. The national TB infection control policy materials and a training curriculum including a health facility TB infection control assessment tool were developed. Training on TB infection control of selected members of hospital staff from 254 health facilities drawn from across the county was done with national leadership, followed by development of IPC plans. The extent and result of the implementation of these plans are however unknown. Additionally, implementing partners have trained staff and supported some sporadic implementation of IPC activities, though MOH ownership has generally been lacking. IPC practices in the country have generally been disjointed, inconsistent, and poorly implemented or non-existent in most health facilities.

Majority of the health facilities in Kenya have not sustained the implementation of TB IPC activities. This sub-optimal IPC implementation has allowed nosocomial transmission of TB to continue. Owing to the nature of most health facilities, significant amount of resources are needed for infrastructural modification to attain the required standards. There is therefore need to engage partners in TB control to ensure that prevention of TB transmission in health facilities is made a priority and adequate resources are allocated. Further opportunities lie in integrating the TB IPC activities into existing general infection control practices to leverage on available resources as well as engagement of county governments and other stakeholders in development of a standard for construction of TB IPC compliant facilities.

Opportunities to leverage on in expanding contact investigation and management include availability of WHO guidelines that can be adapted locally, and availability of successful pilots locally that can inform expansion plans. These pilots have tools and registers that can also be adapted nationally. Gaps include lack of policy, guidelines and tools for contact investigation and management, as well as limited financial resources for scale-up. These gaps need to be addressed.

b) Contact Tracing

Active TB case finding among contact TB patients has been demonstrated to yield a high number of active and Latent TB cases. In 2013, Kenya notified a large number of infectious TB cases, including 34,643 smear positive PTB and 285 MDR-TB. Some 7,403 childhood TB cases were also notified. National guidelines recommend investigation and management of household contacts of all smear positive PTB and DR TB cases. While the guidelines are silent on screening household contacts of children index TB cases, new evidence recommends this. There is no national data on contact tracing, including the number of eligible contacts for screening, as well as number or proportions screened and their outcomes. Kenyan studies suggest that each adult TB index patient has 0.41 household contacts aged less than 5 years, in addition to older children and adults who would benefit from screening.

Implementation of TB contact tracing in Kenya is largely unstructured and lacks official tools and registers. The services are

_______________________________________________________________________________________________________________________________

1 D. Guwatudde, M. N., E. C. Jones-Lopez, A. Maganda, A. Chiunda, R. D. and J. J. E. Mugerwa, G. Bukenya, and C. C. Whalen (2003). “Tuberculosis in Household Contacts of

Infectious Cases in Kampala, Uganda.” American Journal of Epidemiology 158(9).

140

While WHO has issued guidance on contact investigation, national guidelines recommend screening of contacts of infectious TB, including MDR-TB, but do not describe how this should be done. Also, tools to support this, including registers, are not available. Kenya pediatric TB guidelines, while describing what should be done for children less than five years old (IPT for those without TB), do not describe what method of screening should be carried out, and are silent on recommendations for older children. This lack of clear guidance has resulted in very little contact investigation as established during the MTR. It was not routinely carried out at most health facilities. This therefore constrains efforts to identify new TB cases early and to issue Isoniazid Preventive Therapy (IPT) to minimize TB incidence among asymptomatic contacts.

Opportunities to leverage on in expanding contact investigation and management include availability of WHO guidelines that can be adapted locally and availability of successful pilots locally that can inform expansion plans. These pilots have tools and registers that can also be adapted or adopted nationally. Gaps include lack of policy, guidelines and tools for contact investigation and management, as well as limited financial resources for scale-up. These gaps need to be addressed.

c) Isoniazid Preventive Therapy (IPT)

By end of April 2014, 615,621 PLHIV and 61,588 CLHIV were on ART in Kenya. Guidelines recommend routine screening for TB among PLHIV and placement on IPT for those who are asymptomatic. Of PLHIV screened for TB, 80% will screen negative, hence are eligible for IPT. Among children less than five years who are household contacts of patients with smear positive PTB, 10% are likely to have secondary TB, hence 90% will be eligible for IPT. Despite these figures of persons eligible for IPT, only 600 children aged less than five years exposed to smear positive PTB and approximately 5,600 PLHIV, including CLHIV were initiated on IPT in 2013, according to the TB health information system TIBU.

While the current policy provide for IPT for children less than 5 years exposed to PTB+ and PLHIV, the uptake is low. Implementation is scanty, particularly for PLHIV. It varies greatly, depending on implementing partners’ support. The MTR found the uptake of IPT to be very low everywhere, with almost universal unavailability of IPT registers and tools. A skills gap was identified among HCWs in use of IPT, and many still had misconceptions that IPT would result in development of DR TB strains. Guidelines on IPT use, while existent, were not available at facilities, and job aids were missing. The MTR further found that while ICF for PLHIV uptake was good (82% of PLHIV screened), uptake of IPT was quite low with only 2% of those eligible on it.

Opportunities to support IPT use include the current TB and HIV policies and guidelines that provide for IPT, creating an enabling policy environment for implementation and scale-up. Further, there have been successful pilots of IPT implementation, from which best practices and lessons can be shared and which can host exchange programs. Many of these pilots have also embedded continuous quality improvement plans in their implementation, which can be adapted during scale-up. The recent increase in interest and willingness to support IPT from development and implementing partners also serves as an opportunity to scale-up. Gaps include less than optimal TB/HIV coordination at national and county levels; inconsistent IPT commodity availability; and knowledge, skill and attitude gaps, both among service providers and managers.

4.5.

1 IP

C, C

onta

ct T

raci

ng a

nd IP

T

carried out in an ad hoc manner, with great variation across the country. While guidelines provide for contact tracing for children under 5 years of age exposed to smear positive TB, this is poorly done in some cases, with only 1% being screened. National guidelines are silent on tracing of contacts of index pediatric TB cases. The midterm review found that contact investigation and management is not routinely practiced at most health facilities, with most staff not convinced of the benefits of contact management. There was particular concern that IPT might result in development of resistant strains of TB.

141

4.5.1 IPC, Contact Tracing and IPT

Strategic Direction(s) for 2015-2018

a) Intensifying early case finding through structured contact tracing. b) Scale-up of IPT with a focus to reach all eligible PLHIV and children exposed to PTB+.c) Accelerate the operationalization of infection control plans, starting in high-volume facilities

3. Proposed Approaches

a) Mainstream IPT, IPC and CT into the core functions, guidelines and tools of the NTLD Programi. Revise and disseminate guidelines on CT, IPT and IPC ii. Incorporate aspects of IPC, CT and IPT into all other capacity building and supportive supervision activities of the

NTLD Program. Update TIBU to capture activities related to CT, IPT and IPC.

b) Scale up successful models of IPT for PLHIV and for children in contact with active TB casesi. Ensure INH commodity security, including pediatric formulationsii. Assess provider beliefs and willingness to provide IPT; revise communications and training materials to directly

address misconceptionsiii. Identify and engage centers of excellence for IPT to conduct on-site mentorship and training for new sites. Prioritize

IPT delivery among high-risk populations, such as counties with >5% HIV prevalence in the general population and low ART coverage.

c) Scale-up successful models of contact investigation and management.

i. Sustain ICF and CT efforts in HIV care and treatment settings; and pilot the extension to ICF and CT activities to schools and congregate settings

ii. Expand and intensify contact tracing to cover all household and other close contacts of patients with PTB+, DR TB, pediatric TB (index patients), and leprosy

iii. Establish and roll-out structure contact tracing including guidelines detailing which index cases require contact tracing, steps for conducting contact tracing, dissemination of tools.

d) Operationalize the Infection Prevention and Control plans existing and national and sub-national levels, and expand to other settings:i. Integrate TB IPC in general IPC committees at facilitiesii. Develop and implement TB and TB/HIV work place policies to promote infection control iii. Leveraging on other ministries e.g. housing, to embed IPC in planning policiesiv. Allocate resources for health facility infrastructural improvement especially at county level (starting with high

volume facilities).

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Contribution to NSP Impacts Outcomes (IPT, IPC and CT)

Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014

• 75% of all health facilities providing TB services are implementing an infection control strategy

• Increase to 80% the proportion of eligible child contacts who receive IPT

• Increase to 80% the proportion of eligible persons who receive INH

Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018

Increase to 100% the child and other close contacts of DR TB patients who are screened for TB

Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014

Increase to 80% the proportion of eligible PLHIV who receive IPT

Table 16: Impact and Outcome Indicators for IPT, IPC and CT

4.5.

1 IP

C, C

onta

ct T

raci

ng a

nd IP

T

_______________________________________________________________________________________________________________________________

2 D. Szkwarko, F. O., P. Owiti, E. J. Carter (2013). “Implementing a tuberculosis child contact register to quantify children at risk for tuberculosis and HIV in Eldoret, Kenya.” Public Health

Action 3(3).

3 WHO (2007 ). Tuberculosis: fact sheet no. 104. accessed at: http://www.who.int/mediacentre/factsheets/fs104/en/index.html

4 E. Masini and J.Kangwele(2012).Tuberculosis among public health facility satff in Eastern Province,Kenya.Poster presentation at the World Lung Health Conference in Kuala Lumpur

Malaysia.PC 275-16 pg 235.

5 E. Wahome,1 L. Makori,1 M. Gikera,1 J. Wafula,1 J. Chakaya,2 M. E. Edginton,3 A. M. V. Kumar(2013). Tuberculosis treatment outcomes among hospital workers at a public teaching

and national referral hospital in Kenya. Public Health Journal. Vol 3 no 24 pg 323-327.

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4.5.1 IPC, Contact Tracing and IPT

CHAPTER 5

RESOURCE IMPLICATIONS FOR THE NTLD PROGRAM STRATEGIC PLAN 2015 – 2018Introduction

Health financing provides resources and economic incentives for the operation of health systems. It is a key determinant of health system performance in terms of equity, efficiency, and health outcomes. Health financing also involves providing individuals with a basic package of benefits that is designed to improve health outcomes and ensure financial protection. Health system sustainability has been defined as the “capacity of the health system to replace withdrawn donor funds with funds from other, usually domestic, sources”. Additionally, sustainability of an individual program is defined as the “capacity of the grantee to mobilize the resources to fund the recurrent costs of a project once it is terminated1”.

Evidence shows that higher levels of out of-pocket financing in the health system are correlated with greater incidence of catastrophic payments2. Kenya has over 45% of its population living below the poverty line, with a large share treating financing health care as out-of-pocket expenditure3. Countries with high levels of out-of-pocket spending have limited opportunities for risk pooling, which hinders allocative efficiency and financial protection efforts. Moreover, low overall spending levels result in limited access to essential services and limited financial protection, particularly for the poor. This has resulted in huge inequities in access to health care. Therefore, a reform of the existing health care system by restructuring it to create universal access to health care service is needed.

Preventing individuals from falling into poverty because of catastrophic medical expenses and protecting and improving the health status of individuals and populations by ensuring financial access to essential public and personal health services, provides strong basis for public intervention in financing health systems. Ensuring financial protection means that no household spends so much on health that it falls into and cannot overcome poverty. Achieving adequate levels of financial protection requires maximizing prepayment for insurable health risks; achieving the largest possible pooling of health risks within a population, thereby facilitating redistribution among high and low-risk individuals; ensuring equity through prepayment mechanisms that redistribute costs from low to high-income individuals; and developing purchasing arrangements that promote efficient delivery of good quality services.

This chapter assesses the health financing policy in the fight against Leprosy, Tuberculosis and Lung diseases in Kenya. It analyzes the basic financing challenges facing the NTLD Program as a result of revenue mobilization constraints. The chapter describes in detail, the level of resource requirements for the period of the strategic plan, the available resources and the funding gap. It further sets out likely future costs for some of the key strategies being considered as part of the NSP 2015 to 2018.

Resource Requirements

The Strategic Plan was costed using the Input-Based Costing (IBC) approach. The IBC uses a bottom-up input-based approach, indicating the cost of all inputs required to achieve NSP targets for the financial years of 2014/15 – 2017/18. Over time the rest for all the thematic areas provides important details that will initiate debate and allow the NTLD Program management and development partners to discuss priorities and decide on effective resource allocation. The aim of the costing review is to provide a broad framework on resource requirements as a means of informing donor and government allocations in support of its implementation.

_______________________________________________________________________________________________________________________________ 1 Knowles, Leighton, and Stinson (1997, 39)

2 Xu et al. 2003; van Doorslaer et al. 2005

3 Republic of Kenya, Ministry of Health, National Health Accounts (NHA), 2009/10 indicated that households financed 26 percent of the Total Health Expenditure (THE) for Tuberculosis and Lung diseases.

144

Available Resources (FY 2014/15 – 2017/18)

In the 2001 Abuja Declaration on HIV/AIDS, TB, and other related infectious diseases, African leaders pledged to increase health spending to 15 per cent of their government’s budgets.

The national government’s total budget and the amount allocated to health is usually public information and can be used to evaluate the government’s commitment to health. Information on government health expenditure channeled through the Ministry of Health is usually available through the National Treasury. The global funds have also added a new dynamic to global health policy and a new level of influence over developing countries.

The starting point for estimating available resources is based on budgets and budget projections. These reflect the total amount of available resources. The analysis was done for a four-year period, starting from 2014/15 to 2017/18. Both the Government as well as development partners have planned to commit a total of KES 6.3 Billion to support the NTLD Program for the period of the NSP as shown in the table below.

FY 2014/2015 FY 2015/2016 FY 2016/2017 FY 2017/2018 TOTAL

Source(s) Available Available Available Available Available

Government 1,146,960,426 1,146,960,426 1,146,960,426 1,146,960,426 4,587,841,704

Loans - - - -

Global Fund 736,143,801 680,408,295 - - 1,416,552,096

Other Grants 150,576,816 150,576,816 - - 301,153,632

TOTAL (KES) 2,033,681,043 1,977,945,537 1,146,960,426 1,146,960,426 6,305,547,432

Table 18: Available Resources by Source(s)

According to the Input-Based Costing, the NTLD Program requires KES 26.9 billion for the plan period in order to achieve its targets. This has further been disaggregated by thematic areas as shown in the table below.

Thematic Area (s) FY 2014/2015 FY 2015/2016 FY 2016/2017 FY 2017/2018 TOTAL

Requirement Requirement Requirement Requirement Requirement

TB HIV 475,551,250 501,374,000 476,950,000 275,470,000 1,729,345,250

Childhood TB 163,852,875 722,582,900 690,015,375 631,675,800 2,208,126,950

Lab 414,898,720 365,053,700 369,283,700 359,451,920 1,508,688,040

Leprosy 74,085,200 111,664,000 96,974,000 96,974,000 379,697,200

M & E 325,625,800 712,809,501 314,879,200 336,293,375 1,689,607,876

PAL 107,760,500 266,689,750 257,750,750 197,750,750 829,951,750

Social Protection 658,795,000 656,823,000 652,940,000 662,326,000 2,630,884,000

Commodity 2,018,546,661 1,543,463,842 2,273,678,230 1,775,131,636 7,610,820,369

PPM 51,630,000 113,369,100 115,630,100 115,630,100 396,259,300

Gender 155,759,250 168,397,000 157,580,000 116,227,000 597,963,250

Community Engagement 764,415,000 904,406,250 821,777,250 772,037,250 3,262,635,750

CORE TB 720,881,462 884,040,152 887,167,462 738,620,652 3,230,709,728

Policy and Planning 41,431,200 46,368,200 46,368,200 81,368,200 215,535,800

Communication and Advocacy 222,239,500 140,406,250 157,419,750 143,836,750 663,902,250

PMDR TB 83,637,500 267,485,500 249,373,250 256,231,000 856,727,250

TOTAL (KES) 6,275,476,518 7,401,299,745 7,564,153,867 6,555,391,033 27,796,321,163

Table 17: Resource Requirements by Thematic Area(s)

145

Funding Gap (FY 2014/15 – 2017/18)

This section analyzes financial requirements to achieve the targets outlined in this strategic plan and the available resources. It presents the funding shortfall for the NTLD Program over the NSP period. This involves two steps. First, the use of costing estimates to compute the resource requirements, and secondly, consolidating the available resources and thereafter computing the funding gap for the NTLD Program.

The identification of the funding gap provides an opportunity for potential stakeholders to see when additional resources will be most useful. Overall, the NTLD Program has a funding gap of KES 20.6 Billion over the NSP period of FY 2014/15 to 2017/18 as shown in the table below. The funding gap presents the financing that other stakeholders in the health sector need to come on board and fill.

FY 2014/2015 FY 2015/2016 FY 2016/2017 FY 2017/2018 TOTAL

4,241,795,475 5,423,354,208 6,417,193,441 5,408,430,607 21,490,773,731

Table 19: Funding Gap

Recommendations

A good financing system raises adequate funds for health in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for these services. It provides incentives for providers and users to be efficient4.

The above findings show that funds are likely to be insufficient, thus, there will be need to mobilize more funds from both internal and external sources in order to bridge the funding gap. Actions that need to be taken to mobilize resources include, but are not limited to the following:

• Engage and strengthen the private sector through the Public-Private Partnership (PPP)• The existing PPP model for creation of health post will be strengthened and other areas of the health sector where PPP

can be applied will be explored• Improve financial management• Increase capacity of community health workers’ cooperatives in financial management and mobilize them to investment

in health• Explore all opportunities for grants• Build the capacity in proposal writing and grant application• Sustain and improve performance in grant management• The need to select priorities for funding such as sustaining the high-impact interventions.

Recommendations from the Mid-Term Review

The policy recommendations emanating from the MTR were broadly classified into five (5) thematic areas:

1. Inadequate fiscal space to finance health2. Improving efficiency of sector outlays3. Re-prioritizing spending (within the existing budget)4. Increasing public investments in health5. Improving access to health services.

From the review, the following recommendations have been proposed for the NTLD Program in order to mitigate the financing challenges:

i. The Constitution of Kenya 2010 hints on avenues of financing:a. Apart from direct budgetary allocations at both national and county levels, additional resources can be secured

from the national government’s share of revenue

b. There is need to develop a national and county specific financing strategy to take full advantage of the new public financing opportunities

ii. Intensify advocacy for increased and dedicated national and county level budget allocations

_______________________________________________________________________________________________________________________________4 World Health Organization, 2007: Everybody’s business: Strengthening health systems to improve health outcomes –WHO’s Framework for Action

146

iii. Continue country dialogue on planning and udget process and bring more players on board (where applicable)

iv. Fill the financing gap through supply and demand-side financing

a. Increase availability of services by scaling up health financing innovationsb. Reduced HH out-of-pocket expenditures by expanding the SHI to include more basic and essential services

v. Donor harmonization or alignment among donors in order to reduce fragmentation in financing and service provision (e.g. gains by HS integration, donor pooling)

vi. Work with MOH and Treasury to develop a framework for disbursing conditional grants

vii. Rationalize expected impact outcomes and intervention objectives to match budgets

viii. Annual budget review of NSP to address emerging issues and allow flexibility within budgets for re-allocation

ix. Enhance absorptive capacity through building capacity in the areas of financial management, supply chain management and simplification of the reporting system

x. Promote and monitor programs within county health plans

xi. Leprosy and Lung Disease finance profiling

xii. Establishing linkages between the current social protection strategy and the NTLD Program

xiii. Enhance partnering with the private health sector.

147

ANNEXES

148

ANNEX 1: NSP Writing Team

NAME ORGANIZATION NAME ORGANIZATION

JOY MUTHONI ALP HILLARY CHEBON MOH - HQ (CHSU)

ULO BENSON AMREF HEALTH AFRICA JOYCE MUTHUURI MOH - HQ (GENDER MAINSTREAMING)

MAGDALENE MANG’UT AMREF HEALTH AFRICA KIOGORA GATIMBU MOH - ISIOLO

MARGRET MBURU CDC THOMAS OGARO MOH - NAIROBI

HERMAN WEYENGA CDC WARIARA MUGO MSF

ALICE WAIRIA TB ARC, CHS BEATRICE KIRUBI MSF

JOHN NJENGA TB ARC, CHS CHARLES NJUGUNA MSH

BRENDA MUNGAI TB ARC, CHS PHILIP OWITI MTRH - AMPATH

LORRAINE MUGAMBI – NYABOGA CHS BERNARD MWAURA NACC

KADONDI KASERA CHS SUSAN GACHERI NTLD – PROGRAM

CHRISTY HANSON CHS ANNE KATHURE NTLD – PROGRAM

JANICE NJOROGE CHS RICHARD MUTHOKA NTLD – PROGRAM

RUTH WANJALA TB ARC, CHS MASINI ENOS NTLD – PROGRAM

SHEILLA CHEBORE TB ARC, CHS WESLEY TOMNO NTLD – PROGRAM

ROSE WANDIA TB ARC, CHS NEWTON ANG’WA NTLD – PROGRAM

KINYANJUI SAMUEL TB ARC, CHS JACKSON KIOKO NTLD – PROGRAM

DAVID NJUGUNA CHS ROSE WAMBU NTLD – PROGRAM

FRIDA NJOGU - NDONGWE CHS SAMUEL MISOI NTLD – PROGRAM

CECILIA MWANGI TB ARC, CHS FAITH NGARI NTLD – PROGRAM

HELLEN KALILI CHS CHRISTINE WAMBUGU NTLD – PROGRAM

JOSEPH SITIENEI DCDPC SYLVIA KOECH NTLD – PROGRAM

JESSE WAMBUGU FIND LANGAT BERNARD NTLD – PROGRAM

MAUREEN SYOWAI ICAP KENYA PAMELA JUMA NTRL

GRACE GITONGA KAPTLD RONALD NG’IELA TB ARC, PATH

SAMMY ARITHI KAPTLD OBY OBYERODHYAMBO TB ARC, PATH

ALLAN MALECHE KELIN SUSAN KWAMBOKA TAC

JANE ONG’ANG’O KEMRI LUCY CHESIRE TAC

HEATHER NJUGUNA KEMSA MAURICE MAINA USAID

JOHN MUCHIRI MOH JOEL KANGANGI WHO

PAUL LODI MOH – BUNGOMA HILLARY KIPRUTO WHO

149

ANNEX 2: Stakeholder Meeting Participants

NAME SEX DESIGNATION COUNTY ORGANIZATION

1 A. GIRO TUTU M CTLC ISIOLO MOH - ISIOLO

2 ABDILLE NUR FARAH M CTLC GARISSA MOH - GARISSA

3 ABDULKARIM ZUBERI M CTLC LAMU MOH - LAMU

4 ABRAHAM KIMUTAI M CTLC BARINGO MOH - BARINGO

5 AGATHA MANDU F TB TECHNICAL ADVISOR KISUMU APHIA PLUS NYANZA WESTERN

6 AGERE EGO M CTLC NAKURU MOH - NAKURU

7 AIBAN RONO M M&E OFFICER NAIROBI NTLD - Program

8 ALFRED CHENGWI M CMLC BUNGOMA MOH - BUNGOMA

9 ALFRED KIVISHA M CTLC TRANS NZOIA MOH - TRANS NZOIA

10 ALICE TEBES F CTLC NAKURU MOH - NAKURU

11 ALICE WAIRIA F M & E OFFICER NAIROBI TB ARC, CHS

12 ALWYN KIMALEL M ADMINISTRATION NAIROBI NTLD - Program

13 ANASTASIA MAKENGE F SCMO NAIROBI MOH - NAIROBI

14 ANDOLE MWALE M CTLC KAKAMEGA MOH - KAKAMEGA

15 APOLLO ODONGO M CTLC HOMA BAY MOH - HOMA BAY

16 BEATRICE KARIUKI F CMLC NAKURU MOH - NAKURU

17 BEATRICE KIRUBI F MEDICAL COORDINATOR NAIROBI MSF FRANCE

18 BEATRICE MUIA F CHIEF PHARMACIST KITUI MOH - KITUI

19 BEN KITOLE M SMLT KILIFI MOH - KILIFI

20 BENJAMIN ONYANGO M REGIONAL OFFICER NYANZA/WESTERN TB ARC, CHS

21 BENSON KITOLE M CMLC KILIFI MOH - KILIFI

22 BERNARD BOSIRE M CTLC BUSIA MOH - BUSIA

23 BERNARD LANGAT M PROGRAM OFFICER NAIROBI NTLD - Program

24 BERNARD MACKENZIE M CDH KWALE MOH - KWALE

25 BERNARD SAWE M CTLC ELGEYO MARAKWET MOH - ELGEYO MARAKWET

26 BERTINA MORAA F INTERN NAIROBI NTLD - Program

27 BRENDA BARASA MAKHOHA F CDH KAKAMEGA MOH - KAKAMEGA

28 BRENDA MUNGAI F DEPUTY CHIEF OF PARTY NAIROBI TB ARC, CHS

29 CHAKAYA MUHWA M PHYSICIAN NAIROBI KAPTLD

30 CHARLES BEGI M US NAIROBI DPSM

31 CHARLES ODUOR M DM NAIROBI MOH - NAIROBI

32 CHRISTINE WAMBUGU F PROGRAM OFFICER NAIROBI NTLD Program

33 CHRISTY HANSON F CONSULTANT NAIROBI CHS - KENYA

34 CLAVER KIMATHI M CHIEF PHARMACIST ISIOLO MOH - ISIOLO

35 CONSOLATA WANGECHI F ADMINISTRATION NAIROBI CHS

36 DAVID MUGAMBI M SCMO NAIROBI NTLD - Program

37 DAVID MULEWA M CDH LAMU MOH - LAMU

38 DAVID MUREITHI M CTLC LAIKIPIA MOH - LAIKIPIA

39 DAVID MUSYA M CTLC TAITA TAVETA MOH - TAITA TAVETA

40 DAVID NYAMUHANGA M CTLC MIGORI MOH - MIGORI

41 DECHE SANGA M CTLC KILIFI MOH - KILIFI

42 DINAH ATIENO F CHIEF PHARMACIST BUNGOMA MOH - BUNGOMA

43 DOROTHY MIBEI F EPIDEMIOLOGIST NAIROBI NTLD - Program

44 DRUSILLA NYABOKE F EPIDEMEOLOGIST OFFICER NAIROBI NTLD - Program

45 DUNCAN BARKEBO M REGIONAL OFFICER ISIOLO TB ARC, CHS

46 ELIZABETH CHIRCHIR F CTLC KERICHO MOH - KERICHO

150

NAME SEX DESIGNATION COUNTY ORGANIZATION

47 EMILY KIBUCHI F PROGRAM MANAGER NAIROBI KANCO

48 EMILY NYAGAKI F A. MANAGER NAIROBI WOOF

49 ESTHER ONYANGO F CTLC KISUMU MOH - KISUMU

50 EUNICE KANANA F CTLC MERU MOH - MERU

51 EUNICE MAILU F M & E OFFICER NAIROBI NTLD - Program

52 EUNICE N. KIILU F SCTLC MACHAKOS MOH - MACHAKOS

53 EUNICE OMANYA M HIV/TB MANAGER NAIROBI APHIA PLUS

54 EZEKIEL KAPKURUI M CDH KAJIADO MOH - KAJIADO

55 EZRA KIPROTICH M TECHNICAL ADVISOR NAIROBI CDC

56 FAITH NGARI F PROGRAM OFFICER NAIROBI NTLD - Program

57 FELISTERS MUMA F CTLC NYAMIRA MOH - NYAMIRA

58 FRANCIS K. KIIO M CDH NAROK MOH - NAROK

59 FRANKLIN MWENDA M CTLC KIRINYAGA MOH - KIRINYAGA

60 GIBSON NYAMONGE M BD NAIROBI BD

61 GLORIA KAARI F ADMINISTRATION NAIROBI NTLD - Program

62 GODANA MAMO M REGIONAL OFFICER COAST TB ARC, CHS

63 GRACE GITONGA F NAIROBI KAPTLD

64 HASSAN HUSSEIN M CMLC GARISSA MOH - GARISSA

65 HASSAN IBRAHIM M REGIONAL MANAGER NAIROBI LANCET KENYA

66 HELLEN KALILI F PHARMACIST NAIROBI CHS

67 HENRY KANDIE M ACCOUNTANT NAIROBI NTLD - Program

68 HILLARY KIPRUTO M MEA NAIROBI WHO

69 HILLARY NDIEMA M CTLC UASIN GISHU MOH - UASIN GISHU

70 HIRAM MATHENGE M CTLC NYERI MOH - NYERI

71 HUSSEIN MOHAMMED M CTLC WAJIR MOH - WAJIR

72 J. K. THIONGO M CDH THARAKA NITHI MOH - THARAKA NITHI

73 JACK KIOKO M Program HEAD NAIROBI NTLD - Program

74 JACK MAGARA M CDH NYAMIRA MOH - NYAMIRA

75 JACOB NAKULEU M CTLC TURKANA MOH - TURKANA

76 JAMES GITONGA M CHIEF OFFICER MERU MERU

77 JAMES SEKENTO M PROGRAM OFFICER NAIROBI NTLD - Program

78 JANE ONG'ANG'O F CONSULTANT NAIROBI KEMRI

79 JESSE WAMBUGU M PROGRAM MANAGER NAIROBI FIND

80 JOEL GONDI M CDH MIGORI MOH - MIGORI

81 JOEL KANGANGI M WHO NAIROBI WHO

82 JOHN KANGWELE M SCTLC MAKUENI MOH - MAKUENI

83 JOHN KEMBE M SENIOR PROGRAM OFFICER NAIROBI MOF

84 JOHN NJENGA M M & E SPECIALIST NAIROBI TB ARC, CHS

85 JORAM SUNGUTI M SDA NAIROBI APHIAPLUS KAMILI

86 JOSEPH BETT M HIV/TB MANAGER KERICHO WRP

87 JOSEPH MUKOMA M CTLC MACHAKOS MOH - MACHAKOS

88 JOSEPH NJINJU M CTLC EMBU MOH - EMBU

89 JOSEPH SITIENEI M DIVISION HEAD NAIROBI DIVISION OF COMMUNICABLE DIS-EASE PREVENTION & CONTROL

90 JOSEPHINE MBURU F Program HEAD NAIROBI NTRL

91 JOSPHAT BETT M TBHIV COORDINATOR KERICHO WRP - KERICHO

92 JOY MUTHONI F PROGRAM OFFICER NAIROBI AIDS LAW PROJECT

93 JOYCE KIARIE F PROGRAM OFFICER NAIROBI NTLD - Program

94 JOYCE MUTHUURI F GENDER OFFICER NAIROBI MOH HEADQUARTERS

95 JUDITH OBOBE F M & E OFFICER NAIROBI NTLD - Program

151

NAME SEX DESIGNATION COUNTY ORGANIZATION

96 KADONDI KASERA M ASSISTANT CONSULTANT NAIROBI CHS

97 KANYI W. W. F CDH MURANG'A MOH - MURANG'A

98 KATHURE ANN F PROGRAM OFFICER NAIROBI NTLD - Program

99 KIMANI EVELYNE F CTLC KIAMBU MOH - KIAMBU

100 KIOGORA GATIMBU M PHARMACIST ISIOLO MOH - ISIOLO

101 KIPLAGAT KIPRUTO M CDH KERICHO MOH - KERICHO

102 KIRATHE DICKSON M IT NAIROBI NTLD - Program

103 KOMBO MOHAMMED M CEC HEALTH LAMU LAMU

104 LAMECK DIERO M AMPATH UASIN GISHU AMPATH

105 LILIAN KARIMI F CMLC MERU MOH - MERU

106 LINOY OKOTH M HIV/TB MANAGER NAIROBI APHIAPLUS

107 LUCY IRUNGU F CTLC MURANG'A MOH - MURANG'A

108 LUTOMIA MELSA F CDH BUSIA MOH - BUSIA

109 M. WANYEE F DIRECTOR KIAMBU MOH - KIAMBU

110 MAGDALENE MANGUT F PROGRAM OFFICER NAIROBI AMREF

111 MARGARET NYAMU F CH NAIROBI CHS

112 MARGRET MBURU F CDC NAIROBI CDC

113 MARK MAKOMERE M PHARMACIST NAIROBI ICAP

114 MARTHA MUTHONI F ADMS NAIROBI MOH HEADQUARTERS (HIS)

115 MARY J. WAMBURA F CTLC SIAYA MOH - SIAYA

116 MARY KARIUKI F SENIOR TECHNICAL ADVISOR NAIROBI PATHFINDER INTERNATIONAL

117 MARY OSANO F HAO NAIROBI MOH - NAIROBI

118 MARY SOME F CONSULTANT NAIROBI CHS

119 MASINI ENOS M PROGRAM OFFICER NAIROBI NTLD - Program

120 MATTHEW KYALO M CMLC KITUI MOH - KITUI

121 MAUREEN SYOWAI F HIV C&T ADVISOR NAIROBI ICAP

122 MAURICE MAINA M USAID NAIROBI USAID

123 MELBA KATINDI F PROGRAM OFFICER NAIROBI KELIN

124 MICAH CHEBURET M CTLC NAROK MOH - NANDI

125 MICHAEL NYACHAE M PHARMACIST MIGORI MOH - MIGORI

126 MICHAEL OWIGI M PSK NAIROBI PSK

127 MIURA TAKASH M LAB TECHNICAL ADVISOR NAIROBI JICA

128 MOLU HUKA M CDH ISIOLO MOH - ISIOLO

129 MUIA BEATRICE F CHIEF PHARMACIST KITUI MOH - KITUI

130 NDUTA WAWERU F PROGRAM OFFICER NAIROBI NTLD - Program

131 NEWTON ANGWA OMALE M PHARMACIST NAIROBI NTLD - Program

132 NG'IELA RONALD M TECHNICAL ADVISOR NAIROBI TBARC, PATH

133 NICHOLAS NJERU M CTLC THARAKA NITHI MOH - THARAKA NITHI

134 NOUH D. ABDILLAHI M CTLC MANDERA MOH - MANDERA

135 NYACHAE MICHAEL M CHIEF PHARMACIST MIGORI MOH - MIGORI

136 OBADIAH NJUGUNA M PROGRAM OFFICER NAIROBI NTLD - Program

137 OBY OBYERODHYAMBO M STRATEGIC COMMUNICATIONS NAIROBI PATH

138 OKOTU BORU M CTLC MARSABIT MOH - MARSABIT

139 OLGA MASHEDI F RESEARCH OFFICER NAIROBI KEMRI

140 OMONDI JOHN M CTLC KISII MOH - KISII

141 OWATTO H. OBBO M ACHP NAIROBI HPU

142 PAMELA JUMA F PROGRAM OFFICER NAIROBI NTRL

143 PAUL KIAGE M M&E OFFICER NAIROBI COMMUNICATIONS AUTHORITY OF KENYA

152

NAME SEX DESIGNATION COUNTY ORGANIZATION

144 PAUL LODI M CTLC BUNGOMA MOH - BUNGOMA

145 PAUL WEKESA M CEO NAIROBI CHS

146 PETER MULWA M SENIOR ECONOMIST NAIROBI MINISTRY OF LABOUR AND SOCIAL SERVICES

147 PHILIP MBITHI M CDH TRANSNZOIA MOH - TRANSNZOIA

148 PHILOMENA ATSIANYA F CTLC NYANDARUA MOH - NYANDARUA

149 PIUS KIOKO M CTLC KITUI MOH - KITUI

150 RACHEL MALOWA F PROGRAM OFFICER NAIROBI TAC

151 RAPHAEL GIKERA M PO NAIROBI AKMLSO

152 RICHARD KIPLIMO M M&E OFFICER NAIROBI NTLD - Program

153 RICHARD MUTHOKA M PROGRAM OFFICER NAIROBI NTLD - Program

154 ROSE BARAZA F SCTLC VIHIGA MOH - VIHIGA

155 ROSE MUTHEE F S.O. NAIROBI NTLD - Program

156 ROSE WAMBU F PROGRAM OFFICER NAIROBI NTLD - Program

157 ROSE WANDIA F ADVOCACY OFFICER NAIROBI TB ARC, CHS

158 RUTH WANJALA F COMMUNICATION OFFICER NAIROBI CHS

159 SALIM GARISE M CTLC TANA RIVER MOH - TANA RIVER

160 SALOME WANJOHI F HCM NAIROBI AAR

161 SAMMY ARITHI M PROGRAM OFFICER NAIROBI KAPTLD

162 SAMMY OSORE M CDH ELGEYO MARAKWET MOH - ELGEYO MARAKWET

163 SAMMY ROP M CTLC NANDI MOH - NANDI

164 SAMSON KIOKO M CTLC MOMBASA MOH - MOMBASA

165 SAMUEL BARGOTIO M CTLC WEST POKOT MOH - WEST POKOT

166 SAMUEL KINYANJUI M CHIEF OF PARTY NAIROBI TB ARC, CHS

167 SAMUEL MISOI M PROGRAM OFFICER NAIROBI NTLD - Program

168 SHEILLA CHEBORE F LAB TECHNICAL OFFICER NAIROBI TB ARC, CHS

169 SHOBHA N. VAKIL F TECHNICAL ADVISOR NAIROBI NASCOP - Program

170 SOLONKA PILIPILI M CTLC KAJIADO MOH - KAJIADO

171 SOME ELIAD M CONSULTANT NAIROBI CHS

172 STEPHEN MURAGE M CTLC SAMBURU MOH - SAMBURU

173 SULEIMAN MWATENGA M CMLC TAITA TAVETA MOH - TAITA TAVETA

174 SUSAN GACHERI F PO NAIROBI MOH- NAIROBI

175 SYLVIA KOECH F INTERN NAIROBI NTLD - Program

176 THOMAS OGARO M CTLC NAIROBI MOH - NAIROBI

177 TIMOTHY KANDIE M ICT OFFICER NAIROBI TB ARC, CHS

178 VALENTINE NGELESO F CHIEF PHARMACIST LAIKIPIA MOH - LAIKIPIA

179 VICTORIA NGENO F SCTLC BOMET MOH - BOMET

180 WALTER MUKHWANA M LFA NAIROBI PWC

181 WESLEY TOMNO M PO NAIROBI NTLD - Program

182 WILLIAM MURAAH M CEC HEALTH MERU MERU

183 WINNIE MIGWI F SMLT NAKURU MOH - NAKURU

184 Z. KARIUKI GICHUKI M CEC HEALTH NYANDARUA NYANDARUA

185 MAUREEN KAMENE F PROGRAM OFFICER NAIROBI NTLD - Program

186 KEVIN CAIN M KISUMU CDC

187 KHAIRUNISA SULEIMAN F PUBLIC HEALTH CONSULTANT

188 SIBUSISO HJATJWAKO M AERAS

189 EVANS AMUKOYE M DIRECTOR - CRDR NAIROBI KEMRI

190 ELIZABETH OBIMBO F PEDIATRIC PULMONOLOGIST NAIROBI UNIVERSITY OF NAIROBI

191 IRENE MUKUI F PROGRAM MANAGER NAIROBI NASCOP - Program

153

Printed with support from USAID through Tuberculosis Accelerated Response and Care (TB ARC)

For more informantion contact:

National Tuberculosis, Leprosy and Lung Disease Program P.O. Box 20781 - 00202, Nairobi

Email: info@nltp.co.keWebsite: www.nltp.co.ke