Emergency

2005timeline

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Intensified

Support &

Action

Countries

A new initiative to accelerateDOTS expansion with specificfocus on the 2005 WorldHealth Assembly targetssupported by the DOTSExpansion Working Group,the Global Fund to Fight AIDS,Tuberculosis and Malaria,other financial partners,and Stop TB

A new initiative to accelerateDOTS expansion with specificfocus on the 2005 WorldHealth Assembly targetssupported by the DOTSExpansion Working Group,the Global Fund to Fight AIDS,Tuberculosis and Malaria,other financial partners,and Stop TB

Emergency

www.stoptb.org - www.who.int/gtbwww.stoptb.org - www.who.int/gtb

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© 2004 World Health OrganizationAll rights reserved.

Photo credits: Global Partnership to Stop TB Image Library

Design and layout: Bruno Duret

EmergencyIntensified

Support &

Action

Countries

BACKGROUND

Significant progress has been

made towards tuberculosis

control and the targets set by

the World Health Assembly for

2005: to detect at least 70% of the

estimated number of infectious

TB cases and cure 85% of them.

However, an assessment in 2002

revealed that, while the average

treatment success rate in DOTS

programmes is 82%, the case

detection rate has risen steadily

to just 37%, still far from the 70%

target. In addition, TB incidence

has increased dramatically

during the past decade in some

parts of the world (sub-Saharan

African countries with high HIV

prevalence and countries

of the former Soviet Union),

suggesting that TB is a serious

challenge. Overall, the TB

situation represents a global

health emergency that demands

a rapid, precisely-targeted and

intensified response.

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A variety of factors are preventing morerapid progress in case detection and reportingunder DOTS. These include:

• insufficient DOTS coverage of public healthfacilities and access to DOTS services in manycountries;

• the failure of public services, such as hospitalsand other facilities that are seeing TB cases,to deliver DOTS in a coordinated fashion;

• the existence of health services for TB thatdepend on other segments of government(such as ministries of justice, defence, education,etc.) that are not implementing DOTS;

• lack of public awareness and involvementof communities in DOTS activities;

• limited participation by private providers,NGOs, and academic institutions in properTB care delivery as part of national strategiesand programmes;

• limited collaboration between TB and HIVcontrol programmes at all levels, particularlyin high TB/HIV burden countries (HBCs).

Urgent action is therefore needed to accelerateeffective TB control practices and involve all possible care providers, both public andprivate, in order to substantially increasedetection and cure rates in line with the 2005targets, and reduce incidence in line withthe 2015 target of the relevant MillenniumDevelopment Goal (MDG). Thanks to theunprecedented financial resources madeavailable by the Global Fund to Fight AIDS,Tuberculosis and Malaria (GFATM) and otherfinancial partners, such action will now havea genuine chance to succeed.

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Intensified

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Intensified

Support &

Action

Countries

THE EMERGENCY“INTENSIFIED SUPPORT& ACTION COUNTRIES” (ISAC) INITIATIVE

ISAC is a special emergency

initiative to accelerate DOTS

expansion and reach the 2005

targets, within the Global Plan

to Stop TB, and ultimately to

achieve the 2015 target of

reversing TB incidence. ISAC will

focus international assistance

on and support efforts by the

Stop TB Partnership in selected

countries through the DOTS

Expansion Working Group

(DEWG), in order to reach,

first, the 2005 targets and,

subsequently, the MDGs.

Importantly, the DEWG is fully

committed to continuing its

regular efforts to support all

22 HBCs and other countries

in need. ISAC is therefore an

“extraordinary and additional”

effort to accelerate DOTS

expansion and TB control in

selected countries in need

of catalytic action to achieve

the targets.

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Rationale

The international TB community, representedby the DEWG, has an excellent opportunityto maximize the potential of the funding nowavailable (from GFATM, banks and bilaterals)and the current political commitment toTB control. With the significant influx ofresources available in countries, a proportionateincrease in funding is needed for Stop TBtechnical partners to be able to providetechnical assistance so that this unprecedentedopportunity for funding TB control in countriesis not lost. ISAC represents a real chance tostrengthen technical assistance and ensurerapid progress to broaden the scope of nationalTB programme activities, accelerate DOTSexpansion, and involve all care providers in thedelivery of proper TB care and control practices.The Initiative thus responds to the needs of allcountries to reach the TB control targets and atthe same time the specific needs of the donorsto show that the new financial resources areeffectively managed and used to maximumeffect in countries.

Objective

To identify a list of countries, immediatelyready to accelerate TB control activities,for inclusion in Phase I. Technical assistanceto these countries will then be substantiallyincreased in order to support the effectiveabsorption of the newly available resourcesand to catalyse acceleration of TB control.

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Country selection

The following criteria were applied tocountry selection:

• Burden of TB disease and/or of dualTB/HIV infection (absolute numberand/or rate).

• Presence of, or desire to have, in-countrystaff from WHO or Stop TB partners toassist national TB programmes.

• Clear national commitment to andpotential capacity for implementationof TB control activities at country level,plus an enabling environment.

• Availability of substantial funding for TB or TB/HIV control activities fromGFATM, banks, and bilaterals.

• Potential for collaboration with theGlobal Drug Facility on drug procurement.

• Agreement between all levels of WHO,STB partners, and country authoritiesto accelerate DOTS expansion.

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Phase I countries

The Stop TB Partnership, WHO and GFATMjointly drew up an initial list of countries forPhase I of the Initiative during a series ofmeetings in January 2004. These countrieswill benefit from an increase in technicalassistance in order to accelerate or initiatea variety of relevant interventions aimedat promoting the widest DOTS implementationpossible.

India can be acknowledged as a countryin which there is already intensified supportand action by WHO and the STB partners.Sustaining the intensity of those efforts isconsidered key to success in India. The otherselected ISACs are China, Indonesia, Kenya,Pakistan, Romania, Russian Federation,and Uganda (and possibly Peru). WHO willapproach ministries of health to propose andseek support for the Initiative. Detailed actionplans are being prepared with a view tostarting intensive efforts; these will bediscussed within the DEWG core group inorder to win the full support and expressionof commitment by involved partners.

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ISAC APPROACHES

ISAC is based on two approaches:

• Increased financing oftechnical work in countries

Immediate resource mobilization is neededfor technical agencies in the DEWG to startintensified technical assistance and otheressential support to countries throughinvolvement of financial partners. Intensified support implies new resourcesfor various types of technical assistanceby WHO and Stop TB technical partners,and the ISAC Initiative will link specificcountries with financial partners in theDEWG, which will seek resources.

Partners such as CIDA and USAID arealready committed to making extra resourcesavailable to technical agencies in DEWG sothat technical assistance can begin: othermajor donors need to be rapidly identified.

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• Strategic alliance with GFATM

GFATM works in close collaboration with theStop TB Partnership to intensify TB control and document the effects of ISAC in GFATM-supported countries. The technical supportprovided by the DEWG is key to ensuringthe proper implementation, monitoring andevaluation of GFATM-funded projects.

The Stop TB partnership, WHO and GFATMhave therefore agreed that there are at leasttwo mechanisms through which financialresources can be jointly mobilized. The first is the inclusion in GFATM budgets andimplementation plans of additional humanresources for technical work. The second is jointadvocacy to convince donors and financers that the success of GFATM-funded projects willlargely depend on the technical support providedto WHO and the Stop TB technical partners.

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COUNTRY INTERVENTIONS

The ISAC Initiative will be based on avariety of interventions tailored to thesituation of targeted countries. Examplesinclude:

• Intensified technical assistance

Technical assistance will be provided byWHO and relevant Stop TB technicalpartners through placement of in-countryexperts (local and international staff) and frequent missions to provide support at central, intermediate (state, province)and local levels. It will have several aims:

➘ Substantially increased population accessto DOTS services (including involvementof all relevant public and private healthcare providers in TB control) withoutcompromising quality of smearmicroscopy or adequacy of supervision.There is limited participation by privateproviders, NGOs, and academic institutionsin proper TB care delivery as part ofnational strategies and programmes. In order to involve all relevant providers,improved coordination within ministriesof health and among other governmentministries and institutions is essential.

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➘ Rigorous monitoring and evaluation.Intensified monitoring of process andimpact indicators at all levels is critical in ensuring effective and efficient DOTSexpansion and implementation.

➘ Intensified collaborative TB/HIV activities.In many HBCs, HIV is fuelling the TBepidemic and the DOTS strategy alone isinsufficient to control TB. TB programmesmust develop closer collaboration withHIV/AIDS programmes to implement the WHO Interim Policy on CollaborativeTB/HIV Activities to reduce the impact of TB and HIV/AIDS, including supportingantiretroviral treatment projects includedin the “3 x 5” plan (i.e. 3 million people onantiretroviral treatment by 2005).

• Accelerated partnership building

National partnerships and coalitions will bepromoted as a means of involving majorstakeholders in the fight against TB and insupport of national TB programmes in orderto sustain social mobilization and advocacy.

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• In-country advocacy and social mobilization

ISAC will require “seed” funds to accelerateadvocacy and mobilize societies andcommunities, both to increase demand andto contribute to care. This initiative couldrapidly and substantially increase coretechnical competencies and capacities ofnational TB programmes to implement andevaluate large-scale communication andsocial mobilization interventions for TBcontrol in ISAC countries.

• High-level political and advocacy missions

by members of the Stop TB CoordinatingBoard and others. Such missions will behelpful in those countries that are in needof a boost in political commitment.

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MONITORINGAND EVALUATION

ISAC will be closely monitored throughestablished systems to assess progresstowards targets. Importantly, if the ISACInitiative is seen to succeed, additional high-burden and other countries will be targetedfor intensification of efforts in the second half of 2004 in Phase II of country selection.

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lives

sav

ed

A new initiative to accelerateDOTS expansion with specificfocus on the 2005 WorldHealth Assembly targetssupported by the DOTSExpansion Working Group,the Global Fund to Fight AIDS,Tuberculosis and Malaria,other financial partners,and Stop TB

A new initiative to accelerateDOTS expansion with specificfocus on the 2005 WorldHealth Assembly targetssupported by the DOTSExpansion Working Group,the Global Fund to Fight AIDS,Tuberculosis and Malaria,other financial partners,and Stop TB

www.stoptb.org - www.who.int/gtbwww.stoptb.org - www.who.int/gtb