The single concept note details the applicant’s request for Global Fund
resources for a disease component for a three-year period. The concept
note should articulate an ambitious, strategically focused and technically
sound investment, informed by the national health strategy and the national
disease strategic plan. It should represent a prioritized, full expression of
demand for resources, and it should be designed and implemented in a way
that maximizes the strategic impact of the investment. The single concept note
for TB and HIV details the CCM’s request for countries with high co-infection rates
for the two diseases based on data from the World Health Organization.
TB AND HIV
CONCEPT NOTE
Investing for impact against tuberculosis and HIV
Countries with overlapping high burden of tuberculosis (TB) and HIV must submit a single
concept note that presents each specific program in addition to any integrated and joint
programming for the two diseases.
In requiring that the funding requests be presented together in a single concept note, the Global
Fund aims at maximizing the impact of its investments to make an even greater contribution
towards the vision of a world free of the burden of TB and HIV. Enhanced joint HIV and TB
programming will allow to better target resources, to scale up services and to increase their
effectiveness and efficiency, quality and sustainability.
All concept notes should articulate an ambitious, strategically focused and technically sound
investment, informed by the national health strategy and the national disease strategic plans
(NSPs).
The concept note for TB and HIV is divided into the following sections:
Section 1: The description of the country’s epidemiological and health systems context including
barriers to access, the national response to date, country processes for reviewing and revising
the response, and plans for further alignment of the NSPs, policies and interventions for both
diseases.
Section 2: Information on the national funding landscape, additionality and sustainability.
Section 3: The funding request to the Global Fund, including a programmatic gap analysis,
rationale and description of the funding request, as presented in the modular template.
Section 4: Implementation arrangements and risk assessment.
Swaziland TB and HIV Concept Note
04Nov 2014│ 1
SUMMARY INFORMATION
IMPORTANT NOTE: Applicants should refer to the TB and HIV Concept Note Instructions
to complete this template.
Applicant Information
Country
Swaziland
Funding Request
Start Date
2015
Principle Recipient(s)
NERCHA & CANGO
Funding Request
End Date
2017
If the programs are to be managed as separate grants:
Funding Request
Start Date for HIV
Funding Request
End Date for HIV
Principal Recipient(s)
for HIV
Funding Request
Start Date for TB
Funding Request
End Date for TB
Principal Recipient(s)
for TB
FUNDING REQUEST SUMMARY TABLE
A funding request summary table will be automatically generated in the online grant
management platform based on the information presented in the programmatic gap
table and modular templates.
Swaziland TB and HIV Concept Note
04Nov 2014│ 2
SECTION 1: COUNTRY CONTEXT
This section requests information on the country context, including descriptions of the TB
and HIV disease epidemiology and their overlaps, the health systems and community
systems setting, and the human rights situation.
1.1 Country Disease, Health Systems and Community Systems Context
With reference to the latest available epidemiological information for TB and HIV, and in
addition to the portfolio analysis provided by the Global Fund, highlight:
a. The current and evolving epidemiology of the two diseases, including trends and
any significant geographic variations in incidence or prevalence of TB and HIV.
Include information on the prevalence of HIV among TB patients and TB incidence
among people living with HIV/AIDS.
b. Key populations that may have disproportionately low access to prevention,
treatment, care and support services, and the contributing factors to this inequity.
c. Key human rights barriers and gender inequalities that may impede access to
health services.
d. The health systems and community systems context in the country, including any
constraints relevant to effective implementation of the national TB and HIV
programs including joint areas of both programs.
1.1 a) Epidemiology
The Kingdom of Swaziland covers an area of 17,364 km2 and is situated between South
Africa and Mozambique. It has four administrative regions Hhohho, Manzini, Lubombo
and Shiselweni. The population estimates show 1,106,000 in 2014 (a moderate increase
from the 2007 census, which found 1,018,000 residents). Approximately 70% of the
population lives in rural and 30% live in urban areas (UNCT, Swaziland UNDAF: 20112015).
HIV/AIDS
Swaziland is one of the countries with the highest HIV prevalence in the world with 26% of
the population aged 15–49 years living with HIV (Swaziland Demographic and Health
Survey, 2007), and 31% among adults aged 18-49 (Swaziland HIV Incidence Measurement
Survey (SHIMS), 2011). The first case was confirmed in 1986 and prevalence peaked in the
first half of the past decade and started to decline towards the end of the decade. The
human toll of HIV and AIDS in Swaziland is a tragic reality adversely affecting the social
and economic gains, including reversing life expectancy from 60 years in 1997 to 33,7 years
in 2007 (Swaziland Human Development Index, 2007).
Prevalence data from ANC attendees between 15-24 years of age show a steady increase
from 18.9% in 1994 to a peak prevalence of 39.4% in 2002, which then started to decline
reaching 34.7% in 2010 (Fig 1). Heterosexual sex remains the main mode of transmission of
HIV, accounting for 94% of all new HIV infections (MOT, 2009). Risk factors include but
are not limited to multiple and concurrent sexual partnerships, intergenerational and
transactional sex, gender inequalities and gender based violence, low and inconsistent
condom use and low uptake of male circumcision. At present, the epidemic in Swaziland is
stabilizing, but presents wide age, gender and population group disparities.
Swaziland TB and HIV Concept Note
04Nov 2014│ 3
With regard to age, for example, in 2004 the prevalence in the 15-19 year age group ANC
attendees was 32.5% while it was 45.4% for those in the 20-24 years age group (Fig 1).
Prevalence rates by age also differ between men and women with peaks in the 30-34 year
olds for women (54%) and 35–39 year olds age group for men (47%) (SHIMS 2011). This is
likely due to early sexual debut and practice of inter-generational sex among girls with older
men. The practice of intergenerational sex is mainly driven by the local practice whereby
young women are married off to older men or engage in sexual relationships with older and
richer men in exchange for financial and material support (see section below on the drivers
of HIV epidemic).
Figure 1 Trends in HIV prevalence among ANC attendees, 2000-2010
50
45
40
38.4
HIV Prevalence
35
32.3
29.8
30
25
20
45.4
46.3
39.4
39.4
42.5
24.1
32.9
35.4
44.7
40.3
40.8
38.1
34.7
34.6
32.5
29.3
25.6
26.3
26
26.3
20.4
18.8
18.4
17.8
15
10
15 - 19
19 - 24
15 - 24
5
0
1994
1996
1998
2000
2002
2004
2006
2008
2010
Year of ANC Survey
Source: ANC data, GAP 2014
Similarly, there are marked gender disparities, as women are disproportionately affected,
particularly young women. HIV prevalence among women aged 15-24 years was 14.4% in
2011, significantly higher than the 5.9% reported among men of the same age (GAP 2014).
Latest data show that prevalence in the 20-24 years age group had the highest gender
disparity with 7% for men and 31% for women; however this difference narrowed with older
age.
HIV prevalence across the four regions in the country shows no major difference in
distribution as indicated by narrow percentage prevalence ranges (23.1% in Shiselweni,
24.9% in Manzini, 26.2% in Lubombo and 28.9% in Hhohho). However, HIV incidence is
lowest in Hhohho (1.5%) and higher in the other three regions (2.6%, 2.2% and 2.3% for
Manzini, Shiselweni and Lubombo respectively) (Swaziland Demographic and Health
Survey, 2007). The geographic hot spots (i.e. with high commercial sex) are mainly major
urban centres, cross-border points, and towns around major transport and trade corridors.
Key among this is the southern transport corridor between Mozambique and Swaziland
through locations that have amongst the highest HIV prevalence.
According to SHIMS, incidence is 2.38% in the age group of 18-49 year olds, at 1.7% for
men and 3.1% for women. Incidence peaks amongst men aged 30-34 (3.12%) and there are
three peaks for women, 3.8% in 18-19 year olds, 4.2% in 20-24 year olds and 4.1% in 30-35
Swaziland TB and HIV Concept Note
04Nov 2014│ 4
year olds (SHIMS 2011, Fig 2). HIV estimates further confirm that HIV incidence was
2.45% in 2011, and decreased to 1.79% in 2013 and projected to further decrease to 1.52% in
2015 (HIV Estimates and Projections, 2013).
Figure 2: HIV incidence by age group and sex among 18-49 years of age population, 2011
Source: SHIMS 2011
Although the epidemic is characterized as generalized and stable, HIV prevalence is high
among most-at-risk population groups, notably sex workers with a prevalence of 70.3%
(BSS 2011), young women and girls aged 15-24 with 22.9%, and MSM with 17.7% (GAP
2014). Recognizing this, the eNSF emphasizes on strengthening targeted interventions to
most-at-risk population groups including using innovative approaches to reach the
unreached with high-impact interventions.
The main drivers of the HIV epidemic in Swaziland include low and inconsistent condom
use, multiple and concurrent sexual partners, intergenerational sex, low levels of male
circumcision (19% for 15-49years in 2011), and sex work. Barriers include gender
inequalities and GBV, stigma and discrimination. Only 56% of young people aged 15-24
correctly identified ways of preventing sexual transmission of HIV; and 71.5% of sexually
active persons aged 15–49 who had more than one sexual partner in the past 12 months
reported use of a condom during their last intercourse. Condom use among sex workers
with their most recent client was 86%. Condom use among MSM is low (66% with nonregular, 71% with regular partner). The rate of women who self-reported multiple sexual
partners increased from 2% in 2007 to 2.7% in 2010; while for men aged 15-49 it declined
from 23% to 16% during the same period. Intergenerational sex among young women 15-24
years of age doubled from 7% in 2007 to 14% in 2010 (SDHS 2007, MICS 2010, BSS
MARPS 2010). National study on violence documented that 5% of girls were forced to sex
before the age of 18 years and less than half of such incidents are reported (2007). The last
Modes of Transmission study (MOT 2009) identified factors in the spread of the epidemic,
which also are consistent with the above. Key among these are commercial sex, concurrent
multiple sexual partners, intergenerational sex, gender disparities, and gaps in targeted
interventions for key populations. However, considering the dynamics of the epidemic and
barriers to response, another study is justified.
HIV estimates and projections show new infections among children at 18 months declined
from 19.6% in 2009 to 10.1% in 2012. In fact Swaziland has made progress in reducing
mother-to-child transmission of HIV with only 3% of 11,469 HIV-exposed infants testing
HIV positive at 6-8 weeks of birth in 2013. Nevertheless, to ensure elimination of MTCT
there is a need to further reduce transmission during breastfeeding. HIV transmission rate
Swaziland TB and HIV Concept Note
04Nov 2014│ 5
among children remains high (10.1% at 18 months). This is largely attributed to the long
breastfeeding period; delays in detection and starting prophylaxis and interruption of
treatment. To address this, it is important to further strengthen the sequential steps
required for optimal care including counselling and testing, determination for ART
eligibility, infant antiretroviral and cotrimoxazole prophylaxis, early infant diagnosis of
HIV, and ART for HIV-infected infants (refer section 1.2 for details).
Secondary analysis of SHIMS data showed that 85% of PLHIV aged 18-49 who reported to
be on ART were virally suppressed (i.e. <1000 copies/ml) while for those who are aware of
their status but not on ART, only 12% were suppressed, which was very similar to those who
were not aware of their status (10% suppression). This suggests that people who know their
status but do not take any action (i.e. taking ART) are potentially as infectious as people
who are positive but not aware of their status. Similarly, the high viral load in PLHIV who
are not on ART coupled with inconsistent and incorrect use of condoms further contributes
to the spread of HIV infection. This underscores the need for enhanced continuum of care
by intensifying ongoing efforts to scale up HCT, enrolment and retention to treatment and
care programs.
Tuberculosis
Swaziland continues to be severely burdened by the dual TB-HIV epidemic. Current
estimates of TB prevalence are 907/100,000 population, placing the country at the top high
burdened countries in the world1. The estimated incidence is currently at 1,349/100,000
and estimated TB-related mortality (excluding HIV) has stabilized at approximately
63/100,000 population over the last decade. The TB/HIV co-infection rate among incident
TB cases has remained above 80% and equally challenging is the increasing burden of drug
resistant TB cases in the country. Evidently, the evolution of the TB burden has been largely
influenced by the trajectory of the HIV epidemic as depicted by the corresponding increase
in TB case notifications when the epidemic began. The latest estimates of HIV prevalence
among adults aged 15 - 49 years remains high at 26%,2 and the economically active males
aged 25-49 year group remains the most affected by TB in Swaziland as is the case in most
high HIV prevalence settings. Swaziland is making strides in responding to the coepidemics, with 75% TB/HIV co-infected patients receiving ARV treatment in 2013, an
improvement from 35% in 2010. There have been remarkable improvements in the TB
treatment success rate from 68% in 2009 to 76% in 2013, although still below the WHO
target of 85%.
Over the last 5 years, the country has been experiencing a steady decline in TB case
notification rates, contradictory to the trend of WHO estimated TB incidence, which is
continuously increasing. The trends in notification rates over the last 5 years suggest a huge
gap in TB case detection, as based on current case notification the detection rate is 46%. In
2013, 6,665 new and relapse TB cases were notified, translating to a notification rate of 610
per 100,000 population3. This represents a 39% decline from the peak of 1,069 per 100,000
in 2009. While the sustained increase in access to antiretroviral treatment among coinfected TB patients could partly account for this decline, narrow case finding, especially
among high-risk populations may be a contributory constraint. Notably, children account
for only 10% of notified TB cases4.
Figure 3: TB case notification trends 2008– 2013
1Global
TB Report, 2013
Demographic and Health Survey, 2007
3Swaziland Epi Assessment Report 2014
4 NCTP Annual Program Report 2013
2Swaziland
Swaziland TB and HIV Concept Note
04Nov 2014│ 6
Source: Swaziland Epi Assessment Report, 2014
The current national TB notification rate disguises a subtle sub-national variability, with
the Shiselweni region in the southern part of the country reporting rates lower than the rest
of the country in 2013. The Manzini region has notification rates as high as 786 per
100,000 population in 2013, while Hhohho in the north part of the country reported 577
per 100,000 population. Notably, the Shiselweni region has experienced a more significant
decline over the last 5 years.
MDR-TB has emerged as serious threat to the country with total 403 cases in 2013
(Swaziland Epi Assessment Report 2014). A 2009 national Drug Resistance Survey (DRS)
showed an MDR-TB prevalence of 7.7% among new TB cases, and 33.7% among previously
treated TB patients. In 2010, between 7-10% of all new TB cases were multidrug-resistant
(Swaziland Drug Susceptibility Survey, 2010). There was a temporary decline in MDR-TB
notification due to challenges in documentation of GeneXpert MTB/RIF results, which have
since been resolved.
Figure 1: Confirmed MDR-TB cases
450
400
350
300
250
200
150
100
50
0
403
279
242
183
206
196
114
0
2006
2007
2008
2009
2010
2011
2012
2013
Treatment outcomes trends are indicated below. The country might also be missing a lot of
MDR cases due to limited diagnostic capacity. Contributing factors to low treatment
outcomes include delayed bacteriological diagnosis among new cases which led to case
mismanagement and high empirical treatment initiation, which was a consequence of a
highly centralised system, inadequate qualified health personnel and weak 2nd line drug
susceptibility diagnostic capacity.
Swaziland TB and HIV Concept Note
04Nov 2014│ 7
Figure 5: MDR Treatment outcomes 2009, 2010 & 2011 cohorts
70.0
55.6
60.0
50.0
52.9
48.9
43.6
40.0
33.3
31.7
32.6
30.0
20.0
10.0
0.0
2009
Treatment
success
Q1/10
cured
Q2/10
Q3/10
Treatment
completed
Q4/10
Unfavourable
Outcomes
Q1/11
Q2/11
Source: Swaziland Epi Assessment Report, 2014
Explanatory Note:
The country also bears the brunt of the dual TB/HIV epidemics. This is exacerbated by the
high HIV prevalence and the risk of acquiring TB is between 20 and 37 times greater among
people living with HIV. Over 80% of TB patients are HIV positive and TB is responsible for
more than a quarter of deaths among people living with HIV. Swaziland is making strides in
responding to the epidemic, with HTC uptake by TB patients increasing from 86% in 2010
to 96% in 2013. Similarly, at the end of 2013, 75% HIV/TB co-infected patients were
enrolled on ART.
The huge discrepancy between notification rates and estimated burden of TB can be largely
attributed to accessibility and availability limitations. This is more prominent in remote,
rural areas and densely populated urban settings, where socio-economic challenges may
hinder timely care seeking, due to transport and health care cost barriers. In addition,
insufficient active case finding among key populations such as prisoners, mine workers,
children and patients with co-morbid conditions such as diabetes may also be contributing
to low case finding.
The country’s TB case detection is limited to the use of modelled estimates from WHO. The
case detection rate in 2013 stood at 46%, which means that more than 54% of TB cases
remain undetected. The country has an urgent need to conduct a national prevalence survey
in 2015/2016, with a view to review and establish a more accurate measure of TB disease
burden and background epidemiology. Some of the discrepancies in access could also be
attributable to health system-related constraints. There is limited access to TB diagnostic
services, particularly microscopy for treatment monitoring and GeneXpert MTB/Rif
technology, inadequate referral mechanism for sputum collection and transportation to
serve the growing need particularly in rural populations.
1.1 b) Key populations that may have disproportionately low access to
prevention, treatment, care and support services, and the contributing factors
to this inequity.
Swaziland has identified the following population groups as key in the effort to address the
TB/HIV burden in the country. Vulnerable groups at risk of HIV infection include: sex
Swaziland TB and HIV Concept Note
04Nov 2014│ 8
workers, young women and girls, uncircumcised men, migrant populations (truck drivers,
miners, factory workers), men who have sex with men (MSM), and injecting drug users
(IDUs). The challenges faced by sex workers, MSMs and IDU include stigmatization,
discrimination, and criminalization of behaviours, which limit their access to services.
Migrant workers may also not have access to services on transit or at work site. On the
other hand, children, girls and young women, and prisoners are often not economically and
socially empowered to negotiate for their access to prevention and treatment programs.
Thus, designing targeted intervention to reach key populations who are at an increased risk
of HIV infection and TB is critical for success as it maximizes program investment returns.
HIV positive pregnant women are ten times more likely to contract TB, and those who have
TB have a greater likelihood of passing HIV on to their infants during pregnancy, at birth,
or during breastfeeding. While management of TB in children remains a challenge, its
diagnosis is difficult due to non-specific symptoms, lack of effective paediatric diagnostic
tests and child-friendly drug formulations for appropriate treatment and care. Further,
treatment success rate in children is highly dependent on the availability of a reliable,
consistent and consenting caregiver. In Swaziland, data review of the Paediatric TB
management for 2010 showed that children less than 14 years of age account for 15% of all
TB registered cases (1,712/11,140) and 7.5% for those <5yrs (835/11,140). Of the 1,712
registered Paediatric TB cases, 79% (1,361/1,712) were tested for HIV and 71% (971/1361)
were found HIV positive. Of the HIV positive TB infected children, 93% received
Cotrimoxazole prophylaxis but only 33% (317/917) were on ART.
HIV among children remains high and in spite of high coverage of PMTCT (93% of HIV
positive pregnant women on ARV) the HIV transmission rate among children remains high
(10.1% at 18 months). Girls and young women are at risk of HIV infection due to child
marriage and polygamy, which are major factors that result in early sexual debut. Both
practices often result in young women marrying older men, who may be having unprotected
sexual intercourse with a number of women, and with whom they may not be able to
negotiate condom use. In Swaziland 50% of girls had their first sexual experience before 17
years of age; and 31% and 22% of sexually active 15-19 and 20-24 year old girls and young
women had intergenerational sex practice 10 years and above (MICS, 2010). As a result of
these and related practices, HIV disproportionately affects Swazi women, particularly
young women. HIV prevalence among ANC attendee women aged 15-24 years was 14.4% in
2011, significantly higher than the 6% reported among men of the same age (GAP 2014).
Prisons act as a reservoir for TB infection, contributing significantly to community
transmission through staff, visitors and inadequately treated former inmates. A situational
analysis for Swaziland show the prevalence of TB was estimated at 2,400/100,000
population. HIV prevalence among prisoners was 34.9% higher than the general
population. With regard to sexual practices, 41% of inmates alluded to sexual violence in
prisons, 5.1% to having been forced, 2% to having forced others, and 1.6% involved in
consensual sex including transactional sex (A situational assessment on TB, HIV, and
Syphilis in correctional institutions in Swaziland, 2011).
Mineworkers are exposed to factors that compound their risk to both diseases, and these
include poor working conditions, socio-economic factors, lack of knowledge of the
preventive measures and limited access to services. Currently, there are an estimated 6,000
Swazi miners in South Africa and about 22,000 ex-miners who were working in the mining
sector. Recent data show that among 109 mapped miners and ex-miners, 53% had positive
pulmonary TB screening results. Confirmed TB cases including MDR TB were 32% of all
suspected cases. (Implementing the harmonized framework on TB in the mining sector:
Swaziland TB and HIV Concept Note
04Nov 2014│ 9
Swaziland model for one-stop service, Sept 2014). Similar to miners, other migrant
workers travel or stay away from their families for a reasonable period, and are likely to
engage in casual sex with sex workers. As a result, they are more at risk as shown with high
HIV prevalence rates of 26% for sugar cane cutters, and 20% for factory workers. Similarly
out of school youth, who make a pool for migrant workers, had a prevalence of 20.4% (BSS
2011). However, data on TB prevalence among migrant populations (except for miners as
indicated above) is not available. These population groups are often in transit or in
locations with limited access to TB and HIV services, often in crowded conditions,
increasing their risk to TB infection.
Although health workers have the most access to TB and HIV services, it is estimated that
they are two to three times more likely to develop TB (Menzies et al. 2007) and five to six
times more likely to develop MDR-TB than the general population (O’Donnell et al. 2010).
A survey in Swaziland documented that out of 2,315 healthcare workers screened for TB,
31% had symptoms suggestive of TB; and 31% had a positive GeneXpert result, among
whom two were rifampicin resistant. The incidence of TB was 997/100,000 population
(Wellness TB screening project for health care workers in Swaziland, 2014). However, with
regard to HIV where nursing practice are optimally used, the risk from their work is
negligible.
As seen from the high prevalence rate of HIV infection, sex workers are the most vulnerable
population groups due to their nature of work and failure to consistently and correctly use
condoms. Although sex workers live in cities and towns with better access to HIV services,
socioeconomic, cultural barriers and stigma may hinder their optimal use. Nevertheless,
there is high condom use (82%) among sex workers at last sex with their regular client and
89% at last sex with a new client (BSS MARPs 2011). There is no data on the extent of
vulnerability of sex workers to TB because of their work; and as such their risk of TB is
much related to high HIV rates.
The barriers for access of service by MSM and IDU are mainly attributed to self-stigma and
discrimination as both practices are criminalized and socially condemned. Despite these,
however, the group can also access services provided for the general public. Nevertheless, it
is estimated that only 27.1% of MSM have been reached with targeted HIV prevention
information (Extended National Strategic Framework, 2014 – 2018). As a result, condom
use amongst MSM was 66% with non-regular partners and 71% with a regular partner (BSS
MARPS 2011). While the extent and contribution both of practices in the HIV dynamics is
not determined; a size estimation study is ongoing and results are expected by end of 2014
to inform programming.
c) Key human rights barriers and gender inequalities that may impede access
to health services.
Gender inequality is prevalent in all aspects of socio cultural, economic and political areas
of the Swazi society. According to a National Study on Violence against Children and
Women in Swaziland (2007), one in three girls experience sexual violence before the age of
18, and one in four women state that they experience some form of physical violence during
childhood. The national violence surveillance system recorded a total of 8,347 cases of
violence between January 2011 and October 2012; 34% of these involved children. It is
worth noting that more than half of all incidents of child sexual violence go unreported, and
less than one in seven incidents result in a female seeking help (VAC 2007).
Indeed, gender disparities including GBV have limited one’s ability to negotiate the use of
protection, disclosure of HIV status and access to TB and HIV healthcare services. As such,
the HIV epidemic has a gender-bias with more women and girls than their male
counterparts living with or affected by HIV and AIDS. Recognizing the need to address
Swaziland TB and HIV Concept Note
04Nov 2014│ 10
gender issues, the government and partners are working on the integration of gender,
equity and human rights with national policies and programmes and the provision of
gender-sensitive and rights-approach delivery to services.
Latest figures show that public attitudes to HIV and PLHIV are improving. However, the
2011 Stigma and Discrimination Index, which gauged attitudes towards people living with
HIV, found that although stigma has decreased, self-stigma among people with HIV
remains common. Nearly quarters of respondents blame themselves and others for their
infection and reported low self-esteem resulting in low uptake of services (Stigma Index
Report 2011). Another survey also documented traces of stigma and discrimination against
TB cases (13% reported they avoid them) and 15% of the TB case respondents had not
disclosed their status to anyone, which is a cause for concern given the transmission mode
and its high prevalence in the country (NTCP TB Knowledge, Attitudes & Practices Survey
Report 2011).
While there is no nationally representative data on the role of injecting drugs and MSM in
the dynamics of HIV in Swaziland, available information document presence of these
practices. To address this information gap, a mapping study is ongoing. With regard to
rights issues, although both practices are illegal, there are programs targeting the
population groups, coordinated by Technical Working Group constituted of key
stakeholders from public, non-public, and civil society groups.
The Swaziland constitution provides protection for all through the Bill of Rights which
includes protection from discrimination, inequality and inequity, as well as from inhuman
and degrading treatment. The Bill bestows fundamental rights including the right to life
and health (The Constitution of the Kingdom of Swaziland Act, 2005. Chapter III). This is
also emphasized in the Public Health Act of 2004, which promotes non-discrimination in
accessing health services. Supportive policies and bills exist and these include Gender
Policy (2010), Children’s Protection and Welfare Act (2011), Sexual Reproductive Health
and Rights Policy (2012) and the Sexual Offences and Domestic Violence bill (2013).
However implementation of these policies remains a challenge hence the need for
continued advocacy and sensitization of all stakeholders, including law enforcement
agencies. According to the national commitment and policy index study (2013), the country
does not have discriminatory laws and regulations, though certain behaviours are
criminalised e.g. sex work, IDU, MSM and transgender. The study further noted that there
however exist independent national institutions, notably the Human Rights Commission,
for the promotion and protection of human rights. These institutions also consider HIVrelated issues within their work. Overall the human rights and policy environment was
rated as 8 out of 10, by both government and civil society respondents (National
Commitment and Policy Index, 2013).
1.1.d) The health systems and community systems context in the country,
including any constraints relevant to effective implementation of the national
TB and HIV programs including joint areas of both programs.
The health delivery system is structured around a four tier system: public health clinics,
health centres and regional referral hospitals and national referral hospitals (NHSSP 2014).
These four tiers are further structured to health delivery blocks which are linked through
referral systems (Fig 6).
The MOH has developed the National Essential Health Care Package (EHCP) aimed at
improving access to clinical and non-clinical services through a decentralized approach.
The Package defines the services that need to be available for each level (national referral
hospital, regional hospitals, health centres, clinics and community), and informs the type of
structure equipment and human resources to be provided at each level. The EHCP
Swaziland TB and HIV Concept Note
04Nov 2014│ 11
prescribes that all facilities including the primary health care level should be equipped to
prevent, diagnose and treat the three diseases; and to offer reproductive, maternal,
neonatal and child health (RMNCH) services in an integrated manner with an opportunity
to enrol to PMTCT.
Currently, Swaziland allocates approximately 3.8% of its GDP for health services (including
private, 2008). This is projected to increase to 4.3% in 2018 and 4.7% in 2030 (Fiscal
consequences and sustainability of Swaziland’s HIV program, 2013). Government
expenditure on health accounts for 2% of the GDP. The government allocation to the health
sector, although much improved at 11.5% of its budget (2009), still falls short of the Abuja
Declaration which calls upon countries to allocate at least 15 % of their national budget to
health service delivery. The government of Swaziland procures all ARVs (since 2009) and
first-line TB medicines and nearly half of all second-line TB drugs. Furthermore, to improve
efficiency of service delivery, the integration of different services including TB, HIV, and
other curative and preventive services through a decentralized system and doubling of skills
of health workers is underway (HRH Plan 2014-2015).
Figure 6: Linkages in the Health Service Delivery, Swaziland
National Referral
Hospital
Regional Referral
Hospitals
Regional Referral
Hospitals
Health Centres
Regional Referral
Hospitals
Health Centres
Public Health Unit
Public Health Unit
Clinic B
Clinic B
Clinic A
COMMUNITY
Clinic A
Source: Ministry of Health
In addition to the government, the private sector plays an increasing role in delivery of
services, including TB and HIV. According to SAM 2013, out of the 287 facilities available in
the country, 115 (40.1%) are owned by government; 85 (29.7%) by the private sector. 35
(12.2%) are owned by religious organisations and missions, 31 (10.8%) by industries while
20 (7%) by NGOs, respectively. Irrespective of facility ownership, all ARVs, TB and anti
malarial medicines are centrally procured and distributed by the national system and given
to patients for free. Moreover, these facilities also offer HIV testing and TB screening
services. Self-stigma for the middle income to elite population has been reduced through
easy access to privately owned facilities, while workplace facilities offer better access to
employees and their families. On the same note, facilities owned by missionaries and NGOs
also play an important role in availing services to the public in their respective catchment
areas.
The Service Availability Mapping (SAM 2013) reveals that out of the 287 health facilities in
the country (includes General practice facilities, dental clinics and nurse owned clinics), of
Swaziland TB and HIV Concept Note
04Nov 2014│ 12
which 133 (46.3%) facilities provide ART services and only 86 out of the 287 facilities
(29.9%) offer integrated TB/HIV services. An estimated 80% of the public facilities are
initiating ART whilst the remainder of the facilities, which are privately owned, are not
suitable for providing ART services. The government of Swaziland is expanding integrated
TB/HIV services to more HIV service sites and through community systems, including
prevention, case detection, and management; and improve information system for the three
diseases. However, the effort is constrained by lack of adequate number and mix of health
workforce. Whereas WHO recommends a minimum staff-population ratio of 2.5 (doctors,
nurses and midwives) per 1,000 people, the ratio for Swaziland is 1.69 per 1,000 falling
below the recommended minimum (HRH Rapid Assessment, 2009). Furthermore, limited
clinical specialization and continuing professional development hinder quality of
HIV/AIDS and TB services. To address these gaps, a human resource for health strategic
plan (2012-2015) was developed with emphasis on improving planning, management and
development of health workforce. Specific activities include developing a human resource
information system, training of more health workers, review of job descriptions, and
phased-absorption of all donor-funded staff such as for TB, HIV, and Malaria through
national budget (HR Unit Work Plan 2014-2015).
Swaziland also faces health management information system (HMIS) constraints, which
rely heavily on paper-based tools. The April 2013 HMIS Project Review report highlighted
the fragmentation and lack of interoperability of health information databases. Similarly,
the National Health Sector Strategic Plan (NHSSP) notes that there is poor linkage and
inadequate coordination across different sources of health information. As a result, the
quality and timeliness of data is not to the desired level; to improve the current gaps the
NHSSP underscored the need for harmonization and streamlining of health facility forms
and network facilities through a unified mechanism named the Client Management
Information System (CMIS). The CMIS is intended to address gaps in timeliness,
completeness, and accuracy of data, and to reduce duplication in collection and reporting,
thereby improving M&E and HMIS.
There are also constraints in procurement and supply management (PSM) for drugs,
equipment and supplies. Currently, the Ministry of Health’s (MOH) Swaziland Laboratory
Health Services (SLHS) oversees supply chain management of diagnostic commodities for
central laboratories and facility level laboratories while Central Medical Stores (CMS)
oversees distribution of pharmaceutical commodities. The procurement of all health
products is jointly done by the Ministry of Finance Procurement and CMS; however the
procurement of ARVs is done by the Ministry of Finance. The Warehousing Assessment
Report (2014) noted storage constraints and limited capacity for distribution of
commodities due to inadequate transportation systems. Other challenges include lack of
appropriate skills in inventory management, compilation and analysis of data, and weak
laboratory quality assurance system. To address these constraints, the Ministry of Health
has developed a Pharmaceutical Strategic Plan (2012-2016) which is being rolled-out. The
key emphasis of the plan is pharmaceutical administration, legislation and regulation,
procurement and supply, quality monitoring, and human personnel for efficient provision
of pharmaceutical services (NPSP, 2012-2014). Additionally, the Ministry of Health has
developed a Warehousing and Distribution Integration Plan that focuses on ensuring an
integrated supply management approach across the SLHS and CMS and thus incorporates
diagnostic and laboratory commodities into the planned interventions for pharmaceuticals.
The community health system is supported by a number of community actors including
traditional systems, the private sector, government and NGOs. The traditional systems
(volunteers, CBOs, FBOs) provide services such as demand creation, treatment adherence
and support, follow-up defaulters, and health promotion on the three diseases. The private
Swaziland TB and HIV Concept Note
04Nov 2014│ 13
sector is focused on supporting workplace interventions. The NGOs work through
traditional systems by financing and providing technical expertise for the provision of
services, especially in hard to reach communities to complement government efforts.
Government offers community-level services through the services of rural health motivators
who provide primary healthcare services at household levels.
There are 320 rural communities (chiefdoms) and each has an Umphakatsi and 40 wards
within towns, which serve as an entry point for service delivery. Structures have been
established to support programme delivery at community level such as 298 out of 320
umphakatsi have KaGogo Social Centres (KSCs), 37 out of 40 towns/wards have social
centres in urban areas and over 1,550 Neighbourhood Care Points (NCPs) evenly
distributed throughout the country are in place. KaGogo centres serve as coordination
centres for HIV services. To facilitate their participation in health and other social services,
various community structures have been established. These include Tinkhundla
committees, chief’s advisory committees (bandlancane), community development
committees, Lihlombe Lekukhalela Committee, community HIV committees, municipality
coordinating committees, social services related committees, and community volunteers.
These groups work through the above rural and urban-based community administrative
systems.
Community-level activities are also supported by NGOs. At present, there are
approximately 120 non-governmental organisations (NGOs), community based organized
organisations (CBOs) and faith based organisations (FBOs) that are active in the delivery of
TB and HIV services. These institutions provide services to all 360 communities though
service provision is not well coordinated and standardized.
In spite of the invaluable contribution of communities and NGOs in strengthening service
delivery, there is no established referral and reporting mechanism with the health system.
To address these gaps the Ministry of Health has developed a SOP (2014) which will be
implemented in 2015.
1.2 National Disease Strategic Plans
With clear references to the current TB and HIV national disease strategic plan(s) and
supporting documentation (including the name of the annexed documents and specific
page reference), briefly summarize:
a. The key goals, objectives and priority program areas under each of the TB and HIV
programs including those that address joint areas.
b. Implementation to date, including the main outcomes and impact achieved under
the HIV and TB programs. In your response, also include the current
implementation of TB/HIV collaborative activities under the national programs.
c. Limitations to implementation and any lessons learned that will inform future
implementation. In particular, highlight how the inequalities and key constraints
and barriers described in question 1.1 are currently being addressed.
d. The main areas of linkage with the national health strategy, including how
implementation of this strategy impacts the relevant disease outcomes.
e. Country processes for reviewing and revising the national disease strategic plan(s).
Explain the process and timeline for the development of a new plan and describe
how key populations will be meaningfully engaged.
HIV/AIDS Strategic Plan
a) Goals, objectives and priorities
Swaziland HIV program was guided by the national HIV strategic plan 2009-2014.
Following the Joint Mid-Term Review of the National Strategic Framework (NSF) for
Swaziland TB and HIV Concept Note
04Nov 2014│ 14
HIV/AIDS (2009-2014), resulting in the current extended National Multisectoral HIV and
AIDS Framework 2014-2018. The strategy was developed through a multi stakeholder
consultative process, with peer and independent review of drafts by the UNAIDS Regional
Support Team (RATESA) and Technical Advisory Teams from the World Bank (GAMET)
respectively. The extended NSF adopts “investing for results” thinking and incorporates
commitments from the 2011 UN Political Declaration for HIV and AIDS as well as the 2013
WHO Treatment Guidelines (eNSF, 2014-2018). This strategic framework reflects the
national context and has set goal, identified strategic priorities, and high impact
interventions as summarized below.
Goal of the eNSF
Halt the spread of HIV and reverse its impact on Swazi society.
Programmatic Objectives
i.
The HIV testing and counselling programme seeks to ensure that all children,
women and men get tested and know their HIV status.
ii.
The social and behaviour change programme seeks to strengthen public awareness
and comprehensive knowledge of HIV risks and vulnerabilities in order to increase
personal risk reduction and uptake of prevention services.
iii.
The condom promotion and distribution programme seeks to ensure correct and
consistent use of condoms by all sexually active people.
iv.
The prevention of mother to child transmission programme seeks to eliminate new
infections among children and keep mothers alive.
v.
The male circumcision programme seeks to increase the uptake of voluntary
medical male circumcision (VMMC) among all eligible males in Swaziland.
vi.
Improve the availability, access and utilisation of HIV prevention and treatment
services by key populations at higher risk of HIV infections.
vii.
The treatment program seeks to improve the quality of life of PLHIV through
treatment and strengthen treatment as prevention.
viii.
Strengthen the capacity of OVC families to effectively provide comprehensive care
and support for OVC.
ix.
Strengthen national efforts to prevent and manage gender based violence (GBV).
x.
To prevent TB/HIV among PLHIV.
Priority programmes and interventions
i. HIV Testing and Counselling (HTC)
 Innovative service delivery models such as door- to-door counselling and testing,
mobile-testing units, chieftaincy campaigns, bus rank outreaches, dip tanks and
national HTC campaigns, will be used.
 Intensify implementation of HTC strategy to address issues of access, quality,
gender, age of consent, couple and partner testing and key populations.
 Strengthen integration of HTC with other health services and provider initiated
testing and counselling (PIHTC)
 Intensify community mobilisation to create demand for HTC and reduce stigma
and discrimination
 Ensure effective referral to appropriate follow-up services for prevention, treatment
and care services
ii. Social and Behaviour Change (SBC)
 Integrate social and behaviour change interventions in all prioritised eNSF
programme areas, including socio-cultural factors that accentuate HIV vulnerability
and risk.
 Intensify social and behaviour change interventions tailored to specific target
groups as guided by evidence, with intensity and coverage for impact at a
population level.
 Intensify community mobilisation and community referral systems for service
uptake.
Swaziland TB and HIV Concept Note
04Nov 2014│ 15
iii. Condom Promotion and Distribution
• Strengthen condom forecasting, procurement and supply management system
• Intensify access, demand creation and distribution of condoms using multiple
approaches including integration in other health care services.
• Intensify and expand condom distribution coverage for specific targeted groups at
high risk, including young people, men who have sex with men, sex workers and
discordant couples
• Strengthen SBC interventions in condom programming.
• Strengthen M&E and research for condoms.
iv. Prevention of Mother to Child Transmission Programme (PMTCT)
 Intensify the primary prevention of HIV among women of child bearing age.
 Intensify prevention of unintended pregnancies among women living with HIV.
 Prevention of HIV transmission from women living with HIV to their infants
post eight weeks.
 Provision of treatment care and support to mothers living with HIV, their
children and families.
v. Male Circumcision (MC)
•
Strengthen and decentralise MC services especially for neonatal and males aged
10-35 in health and non-health facilities.
•
Intensify education, awareness and community mobilisation to generate
demand and increased benefits of MC for both men and women.
•
Address socio-cultural, myths and misconceptions of MC that create barriers to
service uptake.
•
Integrate MC services with other Health services.
vi. Customized interventions for Key populations
•
Address policies and legal barriers that prevent provision of comprehensive HIV
services to key populations (SW, MSM and IDU) at higher risk of HIV infection.
•
Develop and implement community and institutional based strategies that
address gender, stigma and discrimination.
•
Develop and implement customised strategic interventions targeting key
populations including harm reduction.
•
Carry out research and size estimates to improve knowledge, understanding and
interventions appropriate for key populations.
vi. Treatment, care, and support for PLHIV
•
Reinforce the referral system and tracking mechanisms for PLHIV on ART.
•
Strengthen follow-up of HIV-exposed infants, and children with HIV.
•
Enhance integration of ART services with other health care services such as TB
and SRH.
•
Strengthen community systems to enhance quality and provision of HIV services
for PLHIV including through continuation of nutrition support.
•
Strengthen procurement and supply management for drugs and related
commodities.
vii. TB/HIV Co-infection
•
Intensify the mechanisms for delivering integrated TB and HIV services.
•
Intensify the provision of the Three I’s for HIV/TB.
•
Strengthen health sector capacity to identify and manage XDR and MDR TB.
viii. Care and Support for orphans and vulnerable children (OVC)
• Strengthen family/community systems including alternative care to improve
socialisation and protection and ECCD for OVC.
• Enhance community systems to improve access to affordable HIV services for OVC.
• Financial protection through predictable transfers of cash, food, or other sustainable
livelihood mechanisms for those affected by HIV.
Swaziland TB and HIV Concept Note
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•
•
Advocate for policies, legislation and regulation to meet the needs and uphold the
rights of the most vulnerable and excluded.
Harmonise existing social protection services and strengthen administration and
monitoring of child outcomes.
ix. Gender Based Violence (GBV)
• Strengthen the enabling legal and policy environment and mobilise leadership at all
levels around GBV in young women.
• Strengthen reporting, referral service uptake and prosecution on GBV.
• Generate evidence on GBV.
• Intensify primary prevention addressing gender norms, comprehensive sexuality
education and rights.
• Intensify provision of comprehensive services for management of GBV cases.
b) Implementation to-date, challenges and gaps
The strategy informing the country’s HIV response until the last financial year of 2013/14
was the National Strategic Framework (NSF) for HIV/AIDS (2009-2014). In 2011, a joint
mid-term review of the NSF (2009-2014) was commissioned to assess progress in the
implementation of the strategy (Joint MTR of the NSF (2009-2014)). This MTR as well as
programme reports for 2013/14 inform the implementation to date in this section.
i. HIV testing and counselling (HTC) services: There is a steady increase in the
number of facilities and uptake of HTC services. The number of facilities providing HTC
increased from 147 (77.4%) in 2010 to 264 (92.1%) of health facilities in 2013 (SAM, 2013).
A total of 336,497 HIV tests were performed in public and private health facilities that offer
HTC services in the country in 2013; an increase of 37.7% from the 252,678 HIV tests
performed in 2012 (HIV program report 2013). Interestingly, the proportion of number of
positive tests has been in a downward trend for the last few years, declining from 25.6% in
2009 to 9.7% in 2013 (Figure 7).
Challenges and gaps:
•
Low uptake of HTC, especially amongst men. This presents a significant challenge in
providing targeted prevention and treatment services.
•
Weak linkages between HTC and ART, resulting in delays in treatment initiation.
•
Self-stigma was leading to avoidance of testing and knowing their HIV status.
•
Low HTC for children under the age of 16 due to current guidelines which preclude
children from receiving HTC without parental or guardians’ consent.
Figure 7: Trends in HIV testing and counselling, 2009-2013
Source: HTC Annual Report, 2013
ii. Social and Behaviour Change (SBC): The SBC strategy (2009-2014) was
developed and aimed at guiding implementing partners in the design of individual social
and behaviour change programmes and interventions. A variety of tools that support
implementation of the strategy such as HIV Prevention Toolkit and the Community
Swaziland TB and HIV Concept Note
04Nov 2014│ 17
Conversations Guide have been developed. These have also facilitated integration of SBC
interventions in other programmes such as MC, PMTCT, HTC, condoms and ART. As a
result, 2.7% of women and 16% of men aged 15-49 reported having had sex with more than
one partner in the last 12 months (MICS, 2010). Young people reporting sex before the age
of 15 reduced to 3.8% for women and 2.6% for men in 2010 (MICS, 2010). According to the
National M&E Report for 2011/12 by NERCHA, only 51% of young people aged 15-24 were
reached with social and behaviour change communication programmes.
Challenges and gaps:
•
HIV awareness and knowledge not translated into desired levels of behaviour change
due to inadequate personal risk perception.
•
Difficulties in measuring social and behaviour change, and hence contribution of
interventions on services such as on HIV tests or getting voluntarily circumcised.
•
Often SBC messages are not tailored to target groups at higher risk of HIV infection,
and lack the necessary intensity and coverage to make an impact.
iii. Condom Promotion and Distribution: The MICS (2010) showed that condom
use at last sex among men with more than one partner has improved to 73% and 71%
among women. Provision of condoms for young people in tertiary and vocational
institutions, and those out of school has been intensified with increased use among young
people aged 15-24, at 73.1% and 90.4% among women and men respectively. Condom
procurement is supported by UNFPA, Global Fund, MOH, PEPFAR, PSI and AHF. Free
condoms are distributed by the Ministry of Health, while PSI supports condom social
marketing. Some condoms are available through the retail market. Condom distribution
has declined from 10.6 million in 2010 to 6.5 million in 2011. National condom coverage is
estimated at 41.7% with a national penetration of 44.7%.
Challenges and gaps:
•
Condom promotion and distribution strategies have not adequately targeted
vulnerable groups and key populations at higher risk of infections including women.
•
Correct and consistent condom use is low.
iv. Prevention among key populations: While general knowledge has increased,
progress in preventive practices, such as consistent condom use, is not optimal. For
example, condom use among sex workers at last sex with a regular client was 82% in 2011
(BSS MARPs, 2011). Moreover, there are service gaps for other key populations such as
mobile populations, MSM, and IDUs that pose a challenge for sustaining the current
declining trend in the rate of new HIV infections. Similarly, condom use among MSM
remains low at 66% with non-regular partners. There are no targeted programs neither for
the MSM group nor injectable drug users. To bridge these gaps and improve services for
key populations, a manual for most-at-risk populations was developed and is currently
being implemented. However, there is a need to conduct another modes of transmission
(MOT) study as the last one was conducted five years ago.
Challenges and gaps
•
Inadequate evidence to inform programming for sex workers, MSM, IDU and
uniformed services.
•
Limited targeted HIV prevention services for key populations.
•
Insufficient policies to guide development and delivery of services to key populations.
•
Limited access and utilization of HIV services.
v. Male Circumcision: Swaziland started scaling up of male circumcision (MC) as a
HIV prevention strategy in 2008. A policy was developed in 2009 with a Communication
Strategy in 2011, resulting in an ambitious campaign ‘Accelerated Saturation Initiative
(ASI)’ that attempted to achieve high national male circumcision coverage in a short
period. MC services have been integrated into a majority of public hospitals and health
centres and are also provided through NGO supported fixed sites, outreach, mobile
services and targeted campaigns. Intensified advocacy for MC has resulted in improved MC
Swaziland TB and HIV Concept Note
04Nov 2014│ 18
uptake with 24.3% males aged 15-49 circumcised by 2013 compared to 7% in 2007.
Challenges and gaps
•
Demand for MC services remains low among older men.
•
The current level of MC is not sufficient to yield the aspired macro-level reductions in
new HIV infections.
•
There is low decentralized coverage of service delivery sites and integration of VMMC
with other health services.
vi. Prevention of Mother to Child Transmission (PMTCT): According to the 2013
HIV report, 162 (89%) of the 183 ANC facilities provide PMTCT services. Among those
providing HIV services, 19 (11.7%) have adopted Option B+. As a result, 99% of eligible
women attending ANC (excluding those with proof of HIV positive status during their visit)
received an HIV test. The positivity rate among pregnant women in 2013 was 38.4%. In the
same year, 93% of expected HIV positive pregnant women were on ARVs for PMTCT
(surpassing the global target of 90%). Eligible pregnant women receiving ART for their
own health increased from 40% in 2009 to 72% in 2013.
HIV DNA PCR testing has been decentralized to the primary health care level with 134 sites
testing infants as early as 6 weeks. The uptake has increased from 9,341 infants in 2009 to
13,887 in 2012 and 11,469 in 2013. The proportion of HIV-positive DNA PCR tests
decreased from 10.4% in 2009 to 4.4% in 2013, a decrease of 57.7%. In 2013, 10,750 (95%)
of HIV exposed infants received NVP prophylaxis for PMTCT. HIV infections among
children at 18 months of age are estimated to be 11% of all exposed children in 2013, down
from 19.6% in 2009.
Challenges and gaps:
 High unmet need for family planning (13%) among women of reproductive age (MICS
2010) and higher in the HIV positive women (65%).
 High infant sero-conversion post-8-weeks.
 High maternal mortality rate estimated of 320/100,000 population, and 60% of all
maternal deaths are HIV related.
 Inadequate use of early infant diagnosis (EID) post-8-weeks.
 Low follow up of the mother-baby pair.
vii. Treatment & Care: The ART program was introduced in 2003. The number of ART
facilities increased from 70 in 2008 to 114 in 2010, and to 133 by end of 2012. Currently, all
clients who test HIV positive are referred to pre-ART care, available in all the 133 facilities
(130 initiate and refill; while 3 do only refills). ART enrolments have continued to grow
over the years, averaging 15,300 initiations per year over the last 3 years. This is attributed
to the increase in the number of ART sites, quick turn-round time of CD4 test due to point
of care testing, and introduction of task-shifting from doctor to nurse led ART initiation.
The number of PLHIV on treatment doubled from 55,104 (73.3% of eligible) in 2011 to
103,730 (82% of eligible) by the end of 2013 (CD4 <350mm3). Retention in care at 12
months from initiation of treatment has increased from 77% in 2008 to 86% in 2013.
According to SHIMS, 85% of PLHIV who reported to be on ART were virally suppressed
(eNSF 2014).
Challenges and gaps:
•
Weak referral and patient tracking system: The treatment cascade referral system is
not able to effectively track PLHIV referrals from HTC to ART programmes, resulting
in low and late enrolment to ART and later, poor treatment adherence.
•
Inadequate system for identifying children aged 0-14 who are exposed to or have HIV
resulting in low coverage of ART in children.
•
Occasional stock-outs of CD4 and viral load reagents.
•
Stigma and discrimination remain critical barriers to ART services uptake including
treatment adherence.
viii. TB/HIV Co-infection Management and Treatment
Swaziland TB and HIV Concept Note
04Nov 2014│ 19
Currently 133 facilities provide comprehensive HIV services and 86 (64.7%) of these
facilities have integrated TB services and are fairly distributed across the four regions as
the burden of disease is generalized nationally. The integration of services contributed to
improve the uptake of both services. HIV testing among TB patients reached 92% in 2012
and 80% of these were HIV positive. Conversely, screening for TB among PLHIV has
increased ten-fold from under 20,000 in 2010 to 294,000 in 2012 (National TB
Programme Report, 2012). Approximately 5,184 patients with TB were also co-infected
with HIV in 2013. Of these 3,806 (73%) were placed on both TB treatment and ART; a
sharp rise from an estimated 9.7% in 2011 (GAP 2014).
Challenges and Gaps
•
Inadequate implementation of the Three ‘I’s (Infection control, Isoniazid preventive
therapy, Intensified TB case finding) causes ineffective infection control in
crowded/health facility settings with risk for MDR/XDR TB transmission.
•
Inadequate diagnosis and enrolment of children on to TB, MDR-TB and TB/ART.
Only 45% of children with TB/HIV received ART in 2013.
•
Community involvement in TB/HIV integration remains low. Although both
programs have community-based cadres (adherence counsellors for TB, expert
clients for ART and lay counsellors for HTC), the structures of service delivery
remains parallel.
ix. Care and Support for Orphaned and Vulnerable Children: With more than
half of the country’s population being under 20 years (CSO 2007), Swaziland has at least
229,000 OVC, with one in every fourth Swazi child having lost one or both parents.
Compared to non-orphans (80%), far less percentage of orphans (62%) had their food,
shelter, and education needs met (DHS, 2007). Only 41% of OVC receive any external
assistance and the most common form of support provided was school assistance. Child
malnutrition is a persistent problem, with 38.5% of OVC under age 5 showing signs of long
term nutritional deprivation (stunting), compared to 27.5% of non-OVC (MICS, 2010).
Challenges and gaps:
•
Lack of focus on strengthening the family system: Interventions in socialisation and
protection have tended to target individual children rather than families.
•
OVC initiatives are poorly linked to social welfare services.
•
Inadequate protection of widows and children’s property inheritance rights.
•
Inadequate monitoring, enforcement and compliance to standards on access to
residential and alternative care facilities for children.
x. Gender Based Violence: GBV is still prevalent, with one in three girls reporting
experiencing sexual violence before the age of 18, and one in four women stating that they
experience some form of physical violence during childhood (Study on Violence against
Children and Women, 2007). According to the MICS 2010, 39% of women and 33% of men
aged 15-49 years believe there are circumstances under which hitting their partner could be
justified. In response, the Child Protection and Child Welfare Act (2012) and the Sexual
Offences and Domestic Violence Bill (2013) have been drafted. A large community
volunteer cadre ‘Lihlombe Lekukhalela’ (‘Shoulder to cry on’) were trained to identify and
respond to cases of child violence at the community-level. In addition, a multi-sectoral
national violence surveillance system was established with routine data collation on
incidences of violence and abuse that collects information from nine organisations,
including the Department of Social Welfare (DSW), Royal Swaziland Police (RSP), Ministry
of Education and Training (MoET), Director of Public Prosecution (DPP) and civil society
organisations. Child-friendly corners are established in 24 police stations and childfriendly courts have been established in Mbabane. Toll-free telephone hotlines for
reporting abuse are available and are operated by the Ministry of Education, the Royal
Swazi Police and Swaziland Action Group Against Abuse (SWAGAA).
Challenges and gaps:
Swaziland TB and HIV Concept Note
04Nov 2014│ 20
•
•
Inadequate social services with insufficient number of qualified social workers.
Unclear reporting, case management and referral systems for government structures
as well as for community cadres.
No facilities specialised in providing temporary shelter for survivors of abuse who need
to be temporarily removed from their home to protect them from further abuse.
•
c. Limitations to implementation
Though the above strategies have been identified in the extended NSF, there still remain
the following limitations to implementation:
•
Socio-cultural barriers that impede implementation specifically for service update
and also gender dynamics.
•
Uncoordinated service delivery, especially at community level resulting in
fragmentation of intervention and duplication.
•
Translation of key policies and laws into action remains weak, in some cases due to
lack of knowledge and understanding on these.
•
Information systems are weak, parallel, and heavily rely on paper-based tools;
resulting in inconsistent, incomplete and untimely data. The preliminary HMIS
review report recommends the development of a Client Management Information
System (CMIS) and harmonization and streamlining of health facility forms.
•
Lack of targeted interventions for vulnerable groups and key populations at higher
risk of infections including women.
•
While efforts have been made to ensure health equity, the TB/HIV co-epidemic
increased disease burden has overstretched the existing health system.
•
Whereas WHO recommends a minimum staff-population ratio of 2.5 (doctors,
nurses and midwives) per 1,000 people, the ratio for Swaziland is 1.69:1,000 falling
below the recommended minimum (HRH Rapid Assessment, 2009)
•
The procurement and supply chain management is strained, with limited
warehousing and storage capacity and late payments to supplier.
d) Linkage with the national health strategy
The previous National Health Sector Strategic Plan (NHSSP I, 2009-2013) was formulated
with the following main objectives:
i.
ii.
iii.
iv.
To reduce morbidity, disability and mortality from diseases and social conditions
To enhance health system capacity and performance
To promote effective allocation and management of health and social welfare
resources
To reduce the risk and vulnerability of the country’s population to social welfare
problems as well as the impact thereof.
The HIV NSP was aligned to the National Health Sector Strategic Plan (NHSSP I, 20092013) and guided interventions towards scaling up of HTC (Provider Initiated HTC and
community HTC), expansion of ART eligibility, and decentralization of ART services.
Activities that benefit orphaned and vulnerable children (OVC) included school grants,
universal access to education, and school feeding programs in all primary schools.
The current NHSSP II (2014-2018) is designed to attain universal health coverage with
particular focus on:
i.
ii.
iii.
Increasing the numbers of health and related services and interventions being
provided across the country (introduction of interventions as and where needed)
Increasing the coverage of populations using the different health and related
services and interventions (scale up of intervention use), and
Reducing household financial burden incurred at the point of access and utilization
of health and related services and interventions (reduce catastrophic health
expenditures).
The eNSF is based on the Investing for Results Thinking, which alludes to the UNAIDS ‘90Swaziland TB and HIV Concept Note
04Nov 2014│ 21
90-90 Initiative’ aimed at achieving 90% HIV testing, 90%of those testing HIV positive
receive treatment and 90%of those on treatment virally suppressed. In order to meet these
targets the NHSSP II promotes universal access to care and treatment, including rolling
out of the Essential Health Care Package (EHCP). This entails a rapid scale up of
prevention, testing and treatment services in the next 6 years (to 2020).
Tuberculosis National Strategic Plan (2015-2019)
The goals and objectives of the National TB programme as envisaged in the TB national
strategic plan (2010-2014) are consistent with the national ambitions as enshrined in the
country’s strategic direction, the National Health Sector Strategic Plan (NHSSP) (20092013) and the Essential Health Care Package (2012), which are consistent with the
government decentralization policy. The Swaziland TB NSP 2010-2014 is at tail end of its
implementation, and based on an extensive WHO-led external programme review in April
2014, a new NSP (2015-2019) has been developed in line with the Post 2015 Global TB
Strategy and aims to contribute significantly towards achieving global TB targets.
Therefore, the strategic focus that has informed the prioritized activities as enunciated in
this concept note is based on the incoming NSP (2015-2019).
The TB National Strategic Plan (TB NSP) 2015-2019 aims to achieve a 35% reduction of TB
prevalence rate by 2019, by taking into consideration the lessons learnt from the outgoing
NSP (2010-2014), through the following strategic objectives:
i.
ii.
iii.
iv.
v.
To diagnose and enrol on treatment at least a total of 40,000 TB cases by 2019.
To provide treatment for all diagnosed TB cases and achieve at least 90% treatment
success rate by 2019.
To implement and expand countrywide collaborative TB/HIV activities and
management of co-morbidities by 2019.
To provide treatment and support to all drug-resistant TB cases and reduce the
MDR-TB prevalence rate amongst new TB cases to less than 5% by 2019.
To strengthen the NTCP national TB response management capacity to effectively
coordinate and evaluate TB prevention, treatment and care interventions.
Priority program areas
i.
ii.
iii.
iv.
v.
Increase early case detection and diagnosis.
Improve linkage diagnosed TB patients to treatment and eliminate “pre-treatment
defaulting” and transmission.
Strengthen integrated TB/HIV care, treatment and prevention services.
Decrease the high incidence rate for MDR-TB and reduce mortality.
Address the weak information system (M&E, surveillance, Vital registration).
In line with the Essential Health Care Package (EHCP) and the TB/HIV Decentralization
Framework, SNAP and NTCP have established the following levels of service to coordinate
the decentralization process of integrated TB/HIV services. The levels of service described
below are conceptualized as a “pyramid,” (Annex 1) the base of which is the community and
the apex of which are the national referral hospital or specialized hospitals. In the middle
are the primary health clinics (PHCs). These PHCs (noted as “Level 1”) are the backbone of
decentralized TB/HIV care.
Level 0: PHCs that provide comprehensive pre-ART services: HIV diagnostic testing,
patient registration, clinical and immunological assessment, screening for and
management of opportunistic infection (including TB screening and diagnosis but not
treatment initiation), and prophylaxis (CTX and INH) as well as ART refills. These PHCs
also provide continuation phase TB treatment (DOT, particularly injectables), and access to
Swaziland TB and HIV Concept Note
04Nov 2014│ 22
a community treatment supporter.
Level 1: PHCs that provide the whole HIV and TB service package, including ART initiation
and clinical and laboratory follow-up, daily ARV refills and pre-ART care as per the above.
These clinics also provide access to TB diagnosis and on-site initiation and refills (oral and
injectable) and are known as Basic Management Units (BMUs). Current support systems
(laboratory, drug supply, referral and information systems) are adapted for use at clinic
level.
Level 2: All health centres and regional hospitals provide initiation and continuation phase
TB treatment (oral and injectable), HIV diagnostic testing, CTX prophylaxis, and ART
initiation and refills as well as management of OIs both inpatient and outpatient.
Level 3: The National Referral TB Hospital provides all Level 2 services as well as drug
resistant TB diagnosis, treatment and admission of complicated cases. All Level 2 hospitals
and health centres are equipped to manage complicated HIV cases.
TB/HIV services (including screening) are available in all Public Health facilities and some
private health facilities, which collect samples for testing and refer patients to the 86 BMUs
(Level 1 PHC) for TB and HIV treatment initiation.
Implementation to date and outcomes including impact achieved
The NSP 2010-2014 has facilitated high quality DOTS expansion while addressing TB/HIV
and MDR-TB challenges, contributed to Health System Strengthening and engaging all
health care providers as well as patients and communities in TB control. Additionally, the
NSP has enabled the TB programme to implement important operational research.
High quality DOTS expansion
The current NSP (2010-2014) has realized its objective to pursue high quality DOTS by
strengthening TB diagnostic services through scaling up of basic microscopy services and
the introduction of molecular-based tests for rapid diagnosis of MDR-TB with the
implementation of GeneXpert MTB/RIF assay as the initial diagnostic test for all
presumptive TB cases regardless of HIV status or previous treatment history.
The country is scaling-up Gene Xpert MTB/Rif which has addressed the delay in TB
diagnosis while facilitating early identification of potential MDR cases. Currently, of the 86
Basic Management Units, 26 have TB diagnostic services with 38 GeneXpert machines
strategically distributed across the country’s health facilities, the remaining 59 BMUs are
linked to the GeneXpert laboratories through the National Sample Transportation System
which transports samples for both TB and HIV-related testing (i.e HTC, DBS and POC
CD4) including other disease testing samples. All BMUs have integrated TB/HIV services
from diagnostic to linkage to care. All Hospitals and Health centres and one clinic perform
TB diagnostic services and follow up tests; smear microscopy and Xpert MTB/Rif including
HIV related tests. The TB Diagnostic algorithm is currently being reviewed to reflect
GeneXpert MTB/RIF as the initial diagnostic test for all presumptive TB patients
regardless of HIV or previous TB treatment status as well as the use of 1 st line DST for all
MTB positive and 2nd line DST for all RR cases. Additionally, the NRTL capacity was
upgraded to a Bio-Safety level 3 and now conducts 2nd line DST which was previously
done in South Africa, this has expedite the diagnosis of MDR-TB and appropriate
treatment initiation.
Swaziland TB and HIV Concept Note
04Nov 2014│ 23
A national sample transportation system is in place and has ensured access to TB diagnosis
and linkages to care for peripheral clinics without onsite TB diagnostic facilities. This has
bridged the diagnosis-treatment gap reducing the number of patients with delay of
treatment initiation; however, challenges still exist within diagnosis and treatment
pathways for MDR-TB patients due to delays in confirmatory results of drug resistance
According to the PMDT guidelines RR patients should be immediately initiated on MDR.TB treatment. However, the highly centralized DR-TB Management system has
contributed to the systemic leakages and initial lost to follow-up of patients. This challenge
is being addressed with the ongoing decentralization of DR-TB Treatment initiation sites
and the development of MDR-TB Regional Clinical teams. All health facilities in the
country provide TB screening services and access to TB treatment initiation has increased
through the decentralisation of TB Basic Management Units (BMUs) from 55 in 2010 to 86
in 2014. Involvement of family and community treatment supporters has assisted in
ensuring treatment adherence to TB treatment and patient follow up which has facilitated
improved treatment success rates from 68% in 2010 to 76% in 2013. However, the current
treatment success rates for TB patients (76%) still falls short of global and NSP targets
(Annual TB report, 2013).
To address TB/HIV, MDR/XDR-TB and TB in vulnerable populations:
Through the existence of the National TB/HIV policy, significant strides have been made
with regards to TB/HIV collaboration. The policy facilitated joint planning on cross-cutting
strategic interventions. The NTCP prioritised active TB screening among PLHIV, pregnant
women and prisoners. Through this initiative the TB program detected additional cases
that would have been missed. TB/HIV services are integrated in TB, PMTCT, ART and
OPD units and follow up appointments for TB/HIV patients are synchronized to minimize
losses-to-follow up due to cross referrals. Technical guidelines (TB manuals, MDR-TB
Guidelines, 3Is Guidelines, Infection control Guidelines, HIV care for Adults and
Paediatrics Guidelines, HIV linkages, and HTC Guidelines) have been developed and being
implemented.
To date 86 facilities provide TB/HIV integrated services (one-stop shops), this has resulted
in improved access to ART for TB patients aimed at improving adherence and clinical
outcomes. Through successful implementation of activities under this objective the
program was able to achieve the national targets: 95% of TB patients tested for HIV; 99%
of TB/HIV co-infected patients on CPT, and 75% of TB/HIV patients on ART. These
achievements were above the set NSP targets.
Programmatic management of Drug Resistant TB guidelines and the DR-TB
decentralization plan have guided the step wise decentralization of MDR-TB services to 8
regional health facilities from one central facility (TB Hospital) in 2010. Swaziland uses a
community based MDR-TB care model backed by hospital model for the very sick patients
and these who fulfil the admission criteria such as patients with adherence issues, patients
experiencing severe adverse effects, the vulnerable patients like the orphan, mentally,
socially or physically handicapped. There are two admission facilities in Swaziland, the
national TB hospital and the Nhlangano HC DR-TB ward. The National TB referral
hospital is a referral point for complicated cases and the benefits of decentralizing health
care services are well known and documented to improve access to diagnosis, treatment,
care and support. In addition, to strengthen the quality of DR-TB management, GF has
supported the establishment of MDR-TB regional clinical teams (each team has two MDRTB Doctors and three nurses) to provide technical support at the peripheral MDR-TB
initiation sites as well as conduct home assessments and community-based DR-TB case
Swaziland TB and HIV Concept Note
04Nov 2014│ 24
management. While the initial guidelines recommended that all confirmed MDR cases be
admitted for a minimum of 3 weeks during which patients will be initiated on MDR-TB
intensive treatment, evaluated for HIV and ART eligibility, community treatment support,
drug adverse effects and drug interactions before being discharged for ambulatory care, the
number of hospital beds to not allow admission of all cases. Hence revised guidelines
provide for ambulatory care for stable patients from the onset of treatment. All confirmed
XDR-TB patients will be admitted for until two sputum culture conversion or for a
minimum of 6 months.
Fig : DR-TB Decentralised Model Of Care
The NTCP has developed a capacity building program for health care workers including
support staff at all levels on DR-TB management. Despite the above efforts the treatment
outcomes for MDR-TB patients is still low (58%), however this is a significant
improvement from 33% in 2009 to 58% in 2013 and is above the national set target of 50%
by the end of 2014.
To contribute to Health systems strengthening
Training and deployment of health care workers of different cadres and support staff has
been an ongoing activity, supported by both NTCP GF resources and collaborating
implementing partners. The NTCP contributed to the National Sample Transport System
(NSTS) by donating 5 customised vehicles and 6 motorbikes under the current grant to link
peripheral facilities with the 5 laboratory hubs in the country. Worth noting is that the
NSTS is cross-cutting and the vehicles transport specimens for all disease testing including
HIV, TB and EPI.
Swaziland TB and HIV Concept Note
04Nov 2014│ 25
Engage all care providers, and TB patients and their communities in TB Control
The NSP sought to involve 100% of private practitioners in TB control activities by 2014
and to increase knowledge on TB diagnosis, transmission and treatment to at least 80% of
the population, in order to increase access to TB diagnostic and treatment services,
community awareness and involvement. Community based approaches were strengthened,
e.g. treatment supporters, adherence officers and other existing community structures
(RHMs, Banakekeli) to facilitate community engagement and empowerment. Swaziland
government supports private clinics and hospitals through free supplies of anti-TB
medicines and commodities for TB patient management. The NTCP has engaged 40
private providers through the Stop TB partnership in TB care and this is approximately
50% of the facilities providing TB services.
Limitation to implementation
Since 2010, the country has been experiencing a downward trend in TB case notification
despite the extensive decentralization of TB services and scale up of intensified case finding
among high-risk groups. The burden of TB remains uncertain unless a prevalence survey is
conducted to establish a true burden of TB disease and derive accurate targets. Worth
noting is that the country has integrated routine intensified case finding in all health
facilities, however, access to health services remain a challenge and this may mean missing
patients who cannot access health facilities.
The country is experiencing a challenge in the diagnostic and treatment pathways for
MDR-TB. There is ongoing capacity building to conduct 2nd line DST at the NTRL, which
will address delays in diagnosing extensively drug resistant TB. Treatment success for all
forms of drug susceptible TB is 76%, which is below the global TB targets of 87% owing to
the high death rates and lost to follow up resulting from poor documentation, weak referral
systems and inadequate supportive supervision. Moreover, decentralization of TB
treatment initiation to lower level facilities has been compromised due to inadequate
infrastructure resulting in severe infection prevention and control (IPC) challenges. In
addition, a weak joint TB/HIV M&E system presents challenges of reporting and recording
for TB screening in PMTCT and other HIV sites, which needs to be strengthened.
Despite the government commitment to procurement of TB drugs, the country has
experienced stock outs of TB drugs due to the weak procurement supply chain
management system at all levels and inadequate knowledge of facility HCWs on drug
management.
MDR-TB services are provided in 8 health facilities limiting access to diagnosis and
management of DR-TB at lower level. Further, MDR-TB infection contributes to socioeconomic constraints due to the long period of treatment as patients travel long distance
for follow-up care. The NTCP is experiencing a challenge in bringing services to the
patients due to inadequate human resources. The geographic spread of the DR-TB sites is a
financial burden to most patients that are RR on GeneXpert. All the facilities are currently
concentrated within urban areas, which are less accessible to most patients from rural
areas. Consequently, a lot of patient loss-to-follow-up have been recorded in MDR-TB care
thus expanding care to facilities closer to where people reside will have a direct impact on
loss-to-follow-up, adherence to treatment and subsequently, treatment success rates. The
decentralization of MDR-TB facilities is aimed at making MDR-TB services accessible and
affordable to patients while removing structural barriers to treatment and care. The
additional facilities to be accredited are in Lubombo and Hhohho regions that are both
Swaziland TB and HIV Concept Note
04Nov 2014│ 26
inadequately covered by the MDR-TB care services.
Currently 83% of NTCP and NTRL staff are donor funded and the community outreach
unit of the TB hospital is grossly understaffed to sufficiently support the outreach sites. To
address the problem of inadequate human resources the Ministries of Health and Public
Service have been engaged to develop a Strategy to facilitate the absorption of donorfunded positions within the NTCP into government establishment.
Actions to address limitations:
The government of Swaziland through the MOH is facilitating the strengthening of the
M&E and Vital Registration systems including development of the Client Management
Information System (CMIS) from which the TB programme will also benefit. At the
moment The NTCP in collaboration SNAP is working towards the development of an
integrated TB/HIV reporting and recording tools, to address the weak joint M& E for TB
and HIV.
The Swaziland government has shown commitment by securing a loan from the World
Bank for infrastructure refurbishment, which will partly address IPC challenges in health
facilities to support the BMUs decentralization process. The upcoming NSP have targets to
decentralize TB Treatment initiation sites from 86 to 145 by 2019. In addition, the NTCP
has developed regional MDR-TB management teams comprising of MDR-TB doctors and
nurses who conduct outreach services to underserved areas to strengthen the community
based MDR-TB management.
The national diagnostic algorithm has been modified to facilitate compulsory FLD on all
MTB positive patients and monthly compulsory culture FLD for all MDR-TB patients. The
NTRL has been upgraded to Bio-Safety Level 3 (BSL3) and capacity building for SLD is
being conducted in collaboration with the SNRL in Uganda and FINDx.
To determine the actual TB disease burden in the country the upcoming NSP prioritized
conducting a national TB Prevalence survey in 2016 and a paediatric inventory study in
2017 to ascertain the level of under-reporting of childhood TB. Countrywide expansion in
intensified and active case finding will be implemented during the incoming NSP to
improve current case notification and identify gaps in case detection.
Linkages to national health strategy
The NHSSP (2009-2013) intervention targets for TB control in the country are consistent
with the Global Stop Strategy. The objectives of the NSP 2010-2014 are also consistent with
the NHSSP I and II. Decentralization of TB services is the strategic direction as envisioned
in the NHSSP consistent with the country strategic direction envisaged in the government
decentralization policy. The key interventions of the TB NSP 2015-2019 is to decentralize
services to lower level health facilities and this will reduce the financial and opportunity
costs on TB patients. Furthermore, the NTCP will ensure its services reach all communities
by providing outreach services and active case finding in communities, health care settings
and congregate areas.
TB/HIV linkages between TB and HIV
Although the HIV and TB programs are vertical programs they are both under the
leadership of the DDPH of the Ministry of Health. Since the inception of the TB/HIV
guidelines the country made significant progress in terms of implementing TB/HIV
collaborative activities. The policy has provided a framework to the implementation of
Swaziland TB and HIV Concept Note
04Nov 2014│ 27
TB/HIV integration, facilitated joint planning and incorporated TB and HIV components
in their strategic plans. The TB/HIV National Coordinating Committee (NCC) was
established in 2007 to provide policy direction with regards to TB/HIV collaborative
activities including policy development and review. Provision of TB/HIV integrated
services has improved access to services and promoted a patient-centred approach and
follow up care by one health care provider. The NTCP is in the process of reviewing and
harmonizing its M&E tools to incorporate the necessary TB/HIV indicators.
Development process
The development of the TB NSP was guided by the annual workshop on National Strategic
planning for Tuberculosis Control held in Cepina, Italy in November 2013. Following which
working groups were formed according to thematic areas to guide the development process
of the NSP. From March to April 2014 an external program review of the NSP 2010-2014
led by WHO was conducted in collaboration with SNAP, its main objective was to evaluate
the impact of the TB control efforts in Swaziland, therefore the findings from the review
further informed the 2015-2019 NSP development. The NTCP consulted TB and HIV
stakeholders in community based programmes and CSO (i.e. NCC) and partners for their
inputs to ensure engagement of all relevant parties for successful implementation of the
NSP 2015-2019 strategy development process. CHAI provided technical support to cost the
strategy.
Country processes for reviewing and revising the strategic plans
Swaziland has established the NCC which is also tasked for planning the reviews and
revision of the national HIV and TB strategies. This is coordinated by the NCC through
NERCHA and done through a multi stakeholder consultative process.
The eNSF 2009-2014 was developed through a participatory approach involving key
stakeholders and technical working groups. The costed National Operational Plan (20142017) serves as a tool for joint annual reviews and is spearheaded through different
coordination structures and TWGs. These include TWGs for prevention, treatment, HSS,
TB/HIV and decentralised coordination structures at regional and community levels. The
planning and reviewing process also involves the Regional Multi-sectoral HIV and AIDS
Coordinating Committees (REMCHACC), Public Sector HIV and AIDS Coordination
Committee (PSHACC), Coordinating Assembly of Non-governmental Organisations
(CANGO) and Swaziland Business Coalition on HIV and AIDS (SWABCHA). Development
Partners Coordination is facilitated through existing TWGs as well as the Donors’ Forum
and the Swaziland Partnership Forum. All these structures have been involved in the
development of both the eNSF and NOP, and their own individual plans are aligned to
these national documents.
Technical Working Groups (TWG’s) also holds monthly meetings as part of reviewing and
assessing progress in the national response within their relevant thematic areas. Quarterly
and annual reports are developed and widely shared but also discussed at the TWG
meetings. These reports are informed by data generated from the HMIS and the Swaziland
HIV and AIDS Programme Monitoring System (SHAPMOS), the 2 national M&E systems
for HIV data.
1.3 Joint planning and alignment of TB and HIV Strategies, Policies and
Interventions
Swaziland TB and HIV Concept Note
04Nov 2014│ 28
In order to understand the future plans for joint TB and HIV planning and programming,
briefly describe:
a. Plans for further alignment of the TB and HIV strategies, policies and interventions
at different levels of the health systems and community systems. This should
include a description of i) steps for the improvement of coverage and quality of
services, ii) opportunities for joint implementation of cross-cutting activities, and
iii) expected efficiencies that will result from this joint implementation.
b. The barriers that need to be addressed in this alignment process.
The National TB Control Program (NTCP) and the Swaziland National AIDS Program
(SNAP) are coordinated by the Health Services Directorate with two deputy directors –
Clinical and Public Health, and managed by separate offices under the Ministry of Health,
namely the program managers of SNAP and NTCP. Although the programs develop and
operate under the guidance of independent strategic plans, they both include joint TB/HIV
program activities. In line with the recommendations of the WHO Interim policy on
collaborative TB/HIV activities, and recognizing the need for joint planning, coordination,
and implementation of integrated TB/HIV services in the country, the National TB/HIV
Coordination Committee (NCC) was established in 2007, to provide an oversight for joint
planning, review, monitoring and evaluation. The operations of the NCC are guided by the
National Policy Guidelines on Implementation of Collaborative TB/HIV Activities (2007
and currently under revision).
The revised TB/HIV collaborative framework provides a shared platform and identifies
areas of synergy, including joint planning and review, facility-level service delivery (case
detection, treatment, lab testing, sample transportation), training of healthcare providers,
data reporting, and procurement and distribution of medical supplies. The recommended
practice is to test all TB patients for HIV. Currently, at least 96% of all TB patients are
tested for HIV, and as per national guidelines all TB/HIV co-infected patients are eligible
for CPT and ART. In HIV clinical settings, including among pregnant women attending
ANC, routine TB screening has been integrated into the comprehensive package of care,
with provision of IPT and ART in all eligible PLHIV.
Plans for further alignment of TB and HIV programs
Strategic Planning and Review: HIV and TB programs will do joint planning and
review of both programs; and promote coordinated supervision, data reporting and
monitoring activities. Joint supportive supervision where counterparts from HIV, TB and
the Strategic Information Department (SID) conduct quarterly joint supervision visits will
be strengthened. Efforts will be made to integrate governance at program management and
service delivery levels.
Service Delivery: The target for the coming years is to expand integrated HIV/TB
services from the current 86 facilities to 145 facilities, and to increase uptake and improve
the quality of services in the existing facilities. This will lead to less fragmented services,
higher levels of continuity of care, referral linkages and, proximity of services resulting in
better compliance and good health outcomes. Currently, all TB patients are tested for HIV,
and where necessary provided with CPT and ART services. Likewise, PLHIV and pregnant
women attending ANC are screened for TB and where necessary enrolled on IPT and ART.
Increasing coverage of TB/HIV services will further enhance quality of services and uptake
and adherence for both TB and HIV. Demand creation and retention will be scaled up
using the integrated HIV/TB communication package that is already being piloted in
Manzini.
Health Workforce: The capacity of health workers in the provision of TB/HIV integrated
services, through integrated training curricula, synchronized TB/HIV trainings and
mentoring will be strengthened. Joint capacity building for collaborative activities includes
a well-structured capacity building of nurses through IMAI/NARTIS (integrated TB/HIV)
training will be enhanced by increasing the numbers of Health workforce that will be
trained to provide HIV/TB management. This was facilitated by a review of relevant
Swaziland TB and HIV Concept Note
04Nov 2014│ 29
policies governing medical practice in Swaziland. The nursing scope of practice was
reviewed to facilitate shifting certain tasks from doctors and to other cadres in the health
sector. Review of the policies involved all key stakeholders, including nurses’ and doctors’
associations and the relevant licensing bodies. Through support groups for PLHIV
community-based care and support groups and community-based organisations, TB
prevention, diagnosis, treatment and care will be integrated with those for HIV and vice
versa. Harmonization of TB/HIV community cadres (expert clients and TB Adherence
counsellors) to improve capacity to address both TB and HIV within the communities will
be done.
Health Information System: Current M&E systems are disease-specific and largely
paper-based with components that reflect integration (HTC, ART, CPT in TB registers and
TB screening, TB diagnosis and IPT in ART registers). However, patients have to be doubly
registered and there is movement of patients between registers depending on HIV and/or
TB infection and treatment status. This current information management system — which
is vertical and manual — will be integrated using a single electronic data recording system the Client Management Information System (CMIS) and be rolled-out in all facilities. The
module will track indicators for TB and HIV in an integrated manner.
Procurement and Supply Management: The Swaziland government’s Procurement
Unit and the MOH’s Central Medical Stores (CMS) are responsible for managing the
procurement and supply chain of all health products for patients accessing care at all
public health facilities; and in the case of ARV and TB therapy, the Swaziland government
is responsible for procuring and supplying all 146 facilities. Capacity building of HCWs at
facilities on supply chain management is critical to ensure good storage of medicines and
the prevention of stock-outs, and this will be strengthened to ensure they are able to
manage medicines for both TB and HIV. The ART warehouse used to store isoniazid used
for IPT and dispensed together with the ARVs will be used to also store TB drugs once
expanded.
Laboratory Services: The Swaziland Health Laboratory Services (SHLS) coordinates
diagnostic service delivery and supply chain management in the country. The National
Sample Transport System (NSTS) currently links 118 rural primary healthcare clinics with
5 laboratory hubs where specimens are referred from PHCs for testing and results
transmitted back to facilities. This transport system will be further expanded to ensure that
more health facilities are able to transport specimens (including for TB and HIV) on time.
Potential efficiency gains from integrated TB/HIV services

Integration at the governance level (such as co-ordination of strategic and operation
planning and performance level) will improve technical efficiency by sharing scarce
resources, such as skilled planners and managers. Joint planning and management,
monitoring and evaluation, and reporting will also improve allocative efficiency
from public funds across interventions taking into account the relative costeffectiveness of services.

At the financing level, integration will improve technical efficiency by merging the
costs of separate financing systems. Co-ordinated financing systems will also reduce
perverse incentives that may be created by competing programmes and thus impact
on allocative efficiency.

At the health management systems level, integration will facilitate improvements in
technical efficiency through reductions in management system costs, including joint
procurement, sharing of technical officers, joint training and supervision, sharing of
information, education and communication materials, and joint management
information systems. Joint management information systems improve quality and
timeliness of data through the application of electronic recording system.

At the facility level, integration can contribute to reductions in facility costs resulting
Swaziland TB and HIV Concept Note
04Nov 2014│ 30
from joint utilization of fixed factors of production, “one-stop model” or facilitated
and systematic referral between services.

For patients, integration will lead to less fragmented services, higher levels of
continuum of care, better referral systems and possibly reductions in patient/
community-level costs resulting from fewer visits to facilities, greater proximity of
services and reduced delays in accessing treatment and convenience resulting in
better compliance and good health outcomes
The barriers that need to be addressed in this alignment process include
In addition to the lessons learned, the following bottlenecks to full integration and
alignment will be addressed:
i.
ii.
iii.
iv.
Currently the planning cycles are different for the different programs, there is need
to further align. However, joint planning is already taking place through the
TB/HIV NCC which is currently being decentralized to the regions. Interventions to
address this barrier will include quarterly joint planning meetings between the HIV
and TB program to plan resource mobilization, utilization and evaluation of
progress work plan implementation. The quarterly meetings will be in addition to
the TB/HIV Coordinating committee meetings, except that the joint program
meetings will be strictly for the concerned government departments in order to
increase stewardship.
Guidelines need to be harmonized as current guidelines are developed separately
although collaboratively. The TB progamme released new TB guidelines in 2012
and the HIV programme in 2014. Starting 2016, a joint revision of the guidelines
will be conducted with a view on developing once comprehensive guidelines that
address HIV and TB management. Volume 1 of the comprehensive HIV/TB
management guidelines will focus on comprehensive HIV management guidelines
while volume 2 focusing on comprehensive TB guidelines to ease reference and
usage by health care workers.
Lack of regional TB/HIV coordinating committees need to be strengthened and this
is an opportunity to strengthen the decentralized TB/HIV services. This concept
note provides for the immediate constitution of regional TB/HIV coordinating
committees (RCC) and provides for the resources for the committees to conduct
business. Additional funding to support the operations of the RCC is be sourced
from PEPFAR partners.
Different funding streams exist for the two programs, however, strengthening of
partner coordination through the annual joint planning meetings will ensure
efficiency gains and leveraging of resources whilst minimizing duplication of
efforts..
Efforts are being made to address these challenges. The first step is to establish Regional
Coordination Committees that will be housed in the Regional Health Management teams
(RHMT). Quarterly data reviews are in the process of being combined at the regional and
national level for HIV and TB programs to harmonize the data review process, minimize
amount of time health workers spend at such reviews and guide mentoring and supportive
supervision and the implementation of quality improvement projects. This will promote
further alignment between the two programs in future.
SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND
SUSTAINABILITY
Swaziland TB and HIV Concept Note
04Nov 2014│ 31
To achieve lasting impact against the diseases, financial commitments from domestic
sources must play a key role in a national strategy. Global Fund allocates resources that are
insufficient to address the full cost of a technically sound program. It is therefore critical to
assess how the funding requested fits within the overall funding landscape and how the
national government plans to commit increased resources to the national disease program
and health sector each year.
2.1 Overall Funding Landscape for Upcoming Implementation Period
In order to understand the overall funding landscape of the TB and HIV national programs
and how this funding request fits within these, briefly describe:
a. The availability of funds for each program area and the source of such funding
(government and/or donor). Highlight any program areas that are adequately
resourced (and are therefore not included in the request to the Global Fund).
b. How the proposed Global Fund investment has leveraged other donor resources.
c. For program areas that have significant funding gaps, planned actions to address
these gaps.
Overview: The World Bank classifies Swaziland as a lower middle-income country with a
GDP per capita income of USD $3,042 for 2012. Although this classification would suggest
a reasonable resource base compared to many developing countries, the Swaziland
Household Income and Expenditure Survey (SHIES) 2010 reported that 63% of the
population live under the poverty line and are classified as “poor”, and unemployment
remains high. The government of Swaziland is committed to supporting the health
programs in the country with a focus on the HIV-TB programs given the high burden of
disease individually as well as a high HIV/TB co-infection rate. The following sections
detail the overall funding landscape by disease program.
a) Availability and source of funding
HIV Program: As shown in the Financial Gap template, the government of Swaziland has
demonstrated a high financial commitment to the HIV program (76% counterpart
financing) and its commitments are increasing each year. HIV also receives funding from
various external sources and the country’s partners have committed additional funds to
support the fight against HIV/AIDS for the next three years. Of the $450M cost of the HIV
NOP over the rest of 2014 and the next 3 years, the government (and amounts loaned by
the government) has committed to funding roughly $205M (including funding for HSS
activities), the country’s partners and donors have pledged approximately $184M
(including funding for HSS activities) while the GF existing grants total to about $6M
through the end of 2014. These costs and commitments result in a funding gap of roughly
$57M for the rest of 2014 through March 2018 [Note: Swaziland's fiscal year starts in April
and ends in March the following year. For this exercise, "2012" represents "April 2012March 2013"].
In order to further analyse the financial gaps for FY 2015-17 within each programmatic
area, the HIV program worked with its largest donors (USG, MSF, EU/WB) to break down
their commitments into the broad categories defined in the eNSF. The analysis showed that
certain areas within the HIV program had significant funding gaps given the activities and
interventions planned as part of the NOP over the next few years.
Overall, the major financial gaps were found to be in the buckets below:
 Condom promotion and distribution
 Most-at-risk populations
 ART
 OVC/Family Strengthening
Swaziland TB and HIV Concept Note
04Nov 2014│ 32

Coordination & Management / Human Resources
Some of the other areas such as HTC and pre-ART are expected to have sufficient funding
for the next 3 years. The primary costs associated within the pre-ART deal with
strengthening supply management system for drugs and commodities essential for OI,
ARV drugs and diagnostic reagents. These include:
 Procurement of cotrimoxazole (CTX) for PLHIV for ~$3M over three years
 Procurement of INH & Pyridoxin for Pre-ART patients for ~$1.8M over three years
 Procurement of CD4 tests for Pre-ART patients for ~$1.8M over three years
The government is the largest contributor to the pre-ART program with commitments of
over $18M for FY 2014/15 to FY 2017/18 while PEPFAR contributes roughly $7.3M over
the same period. As a result, pre-ART patients will be sufficiently covered over the next 3
years.
The primary costs associated with the OVC/Family Strengthening include nutritional
support as well as support for school. Nutritional support include $20M of costs for food
over the next 3 years while the school support includes $36M for school fees, supplies,
uniforms etc. While the government and partners have committed over $40M to the OVC
program over the next 3 years, the country will not meet its ambitious targets and needs for
this period due to the large funding gaps. The HIV program will be working with the
government as well as other partners and donors to contribute additional amounts to the
program over the next few years.
The management, coordination and human resource requirements over the next few years
are also expected to be under-funded based on commitments. The program would like to
highlight that the primary driver of the costs is related to HR expenses, which will be
increasing by approximately $3M per year from FY 2015/16 to FY 2017/18 as the program
increases its response to the disease.
In order to obtain an accurate picture of the available future funding, the HIV program
requested donors and partners to confirm that there would be no significant change in
their investment direction over the next three years. The EU/WB confirmed that their
focus within the HIV program will continue to be on the OVC programmatic area. They
have committed a 100% of the EU HIV grant ($2.28M) as well as the WB HIV loan
($2.38M) to OVC. Similarly, MSF confirmed that no significant changes would be made to
their focus areas; however, USG (PEPFAR) would be reallocating some of its resources
from prevention related activities to Treatment related activities. The financial gaps
calculated for FY 2015-17 reflect this change in PEPFAR’s strategy. Partners that have
previously supported the program with funding less than $1M (as calculated by the MOH’s
resource mapping exercise) were assumed to continue their support at that level for the
next 3 years. However, the HIV program did request the partners to inform the program if
any significant contributions will be made in the near future so that they can be accurately
adjusted.
Note that the financial gap analysis for future years is based on the best available data as
of 2014 and both the country as well as the donors realize that some of the gaps
calculated for the analysis may be under estimated. Therefore, programs such as Social
and Behaviour Change, PMTCT, Gender Based Violence and Male Circumcision were
included as part of the request since the programs believed that there are sufficient needs
for these core programmatic areas.
TB Program: HIV was declared a national emergency in 1999 following which TB was
also declared a national emergency on 24 March 2011. This has resulted in increased
political will and resource mobilization to address the dual epidemics. The Government of
Swaziland has demonstrated an increasing level of financial commitment towards the
support of TB, TB/HIV and MDR-/XDR-TB control efforts in the country. A large portion
of the TB program’s budget is financed by the government and the MOH has clearly stated
Swaziland TB and HIV Concept Note
04Nov 2014│ 33
that the TB program along with the HIV/TB structures will continue to be an area of focus
for the Ministry. While the TB program does not have as many partners and donors as the
HIV program, it has received commitments of over $30M covering the period till March
2018. Given the $101M cost of the TB NSP, government commitments of about $36M, and
another $2M of Global Fund’s commitments, the TB program is faced with a $62M gap
over the next three years. Given these commitments from the government and the
anticipated funding being requested from Global Fund for the TB program ($23.5M), the
country is meeting the 40% counterpart financing requirement needed to access the full TB
allocation of GF funding. Upon further analysis of the government expenditures, the
country realized that certain components of the expenses related to the TB hospital and TB
centre were not included in the initial analysis. Including these components added to the
government’s commitments to the TB program and raised the counterpart financing
figures to the current level. Furthermore, the country has reallocated a part of its allocation
to HSS/CSS activities and will be requesting for a lower amount than allocated for the
program.
The program would also like to note that the government commitments for future years are
increasing significantly given the $10.3M World Bank loan signed by the country. This
amount is specific to the TB program and will be spent on the following:
1. Infrastructure: Roughly $6.63M will be spent on medical equipment such as Digital xrays as well as on refurbishment of the TB centre, health centres, and training
institutes.
2. Other: Approximately $3.71M will be spent on HR (cough monitors, co-infection
coordinators, technical assistance, and infection control officers), vehicles, healthcare
waste consumables, blood storage and handling services, and other capacity building
activities.
Using the increased amount of total domestic resources available in the future years, the
counterpart financing for the country specific to the TB program will increase from 43% to
54%. This increase shows the substantial commitment from the government to increase
investments in the TB program.
Finally, to consolidate the financial gaps for FY 2015-17, the TB program worked with its
largest donors (MSF, EU/WB) to break down their commitments into the six broad
objectives defined in the TB NSP. Analyses show that all the objective areas have
significant gaps with the largest gap in objective 4 (to provide treatment and support to all
drug-resistant TB cases and reduce the MDR-TB prevalence rate amongst new TB cases to
less than 5% by 2019).
HSS/CSS Program: Due to the complex and expanding needs of the HSS and CSS
programs, the country did not explicitly perform a financial gap analysis on these
programs. Instead, the country decided to pick out the most critical tasks that are
necessary for an efficient and effective functioning of not only the HIV, TB and Malaria
program but also the health sector. A detailed explanation of these activities and the
rationale for picking the same is provided in Section 3.2 and 3.3.
b) Leverage with other donors
As shown in the financial gap analysis, the country receives support from multiple donors
and partners. PEPFAR stands as the leading donor for the HIV program for the last few
years with Global Fund being the second largest donor in the HIV space. The TB program
receives most of its donor funding from the Global Fund while MSF contributes the next
largest amount. Each program uses the available funding to strategically invest in critical
areas while reducing duplicative efforts and expenditures with the donor funds. In
addition, the donor funding complements the government by funding primarily those areas
with gaps. For the HIV program, the government has previously funded 100% of ARVs
such that Global Fund and partner resources can be leveraged in other critical areas. The
government will continue to be the largest funder within the HIV program especially for
ARVs; however, additional support will be required to cater for the increased ARV demand
Swaziland TB and HIV Concept Note
04Nov 2014│ 34
that will result from adopting the new WHO guidelines. Details on the request for ARVs for
the scale up are in Section 3.
The financial gap analysis by the programmatic areas further shows where the Global Fund
can help the country in reducing the gaps. Given the high disease burden and high coinfection rates in the country, the total cost of high impact interventions is significant and
cannot be covered by any single donor or the government. The analysis provides evidence
that certain donor funds are concentrated on a few critical areas leaving large gaps in
others. For example, all of the available funds for HIV from the EU/WB are focused on the
OVC program as noted above. As such, the Global Fund allocations will be used in those
areas where current government and partner funds are unable to fund the high-impact
interventions mentioned in Section 3.
The Global Fund allocations will also help in strengthening the overall health systems in
Swaziland. Both the HIV and TB programs agree that certain critical interventions that fall
within the PSM, Service Delivery and HMIS areas are not always prioritized by all the
partners and donors. As such, the country has an incredible opportunity to invest
significant resources in the HSS program. While the country receives funding from other
donors for HSS activities (e.g. PEPFAR’s support for implementing the HMIS program as
detailed in Section 3.2.3), the government of Swaziland remains to be the single largest
contributor in the HSS space. Therefore, the three-disease programs have reallocated
$6.7M to HSS/CSS activities for the next 3 years.
c) Gaps and planned actions
One of the largest gaps within the HIV program is within Treatment, Care and Support.
The country is currently requesting $39M to help bridge the gaps in this area by focusing
on the scale up of viral load testing, and other ART related activities. Government and
partners have decided to focus funding on high-impact and critical areas that relate to
ART. However, should the country achieve its targets and notice a decline in the burden of
the disease, the government is open to discussing a strategic shift in funding.
The single largest gap within the TB program falls under objective 4, which deals with
MDR-TB. The country is currently requesting $3.6M to help bridge this gap by focusing on
case detection and treatment, however, a few activities will not be implemented in the near
future due to lack of funds.
The critical gaps within the health sector will be significantly reduced (if not totally
eliminated) given the current allocations to the HSS program.
2.2 Counterpart Financing Requirements
Complete the Financial Gap Analysis and Counterpart Financing Table (Table
1). The counterpart financing requirements are set forth in the Global Fund Eligibility and
Counterpart Financing Policy.
a. For TB and HIV, indicate below whether the counterpart financing requirements
have been met. If not, provide a justification that includes actions planned during
implementation to reach compliance.
Counterpart Financing Requirements
i. Availability of reliable data to assess
compliance
Swaziland TB and HIV Concept Note
Compliant?
☒Yes
If not, provide a brief
justification and
planned actions
☐ No
04Nov 2014│ 35
ii. Minimum threshold government
contribution to disease program (low
income-5%, lower lower-middle income20%, upper lower-middle income-40%,
upper middle income-60%)
☒Yes
☐ No
iii. Increasing government contribution to
disease program
☒Yes
☐ No
b. Compared to previous years, what additional government investments are
committed to the national programs in the next implementation period that counts
towards accessing the willingness-to-pay allocation from the Global Fund. Clearly
specify the interventions or activities that are expected to be financed by the
additional government resources and indicate how realization of these
commitments will be tracked and reported.
c. Provide an assessment of the completeness and reliability of financial data
reported, including any assumptions and caveats associated with the figures.
b) The government has largely focused its resources to fight HIV/AIDS and will continue
its commitment to the program for the foreseeable future. As part of the scale up of VL
monitoring and implementation of the 2013 WHO recommendations, the government
will increase investments to strengthen service delivery and PSM i.e. by employing
doctors, laboratory technologists and improving procurement systems for drugs and
related commodities.
The government will be focusing on a variety of high-impact, underfunded
interventions in the diseases programs to help support the response. For example, the
MOH will be focusing on the OVC feeding program in the coming years to ensure that
they are adequately cared. The MOH is also looking for sustainable enablers that will
capacitate the OVC to feed themselves in the long run.
The government will also be spending some of its resources in the procurement of
vaccines for preventing cervical cancer, which is known to be driven by the HIV
epidemic. Preliminary assessment of vaccine costs show that it is expensive and it will
consume a significant proportion of government resources allocated to health
interventions. In addition, government will continue to absorb donor-funded positions
at a steady pace and take full ownership of the new initiatives in the health sector (e.g.
HMIS electronic patient management platform elaborated in Section 3.3). A high level
breakdown of the major areas where government funding will increase is shown on the
‘W2P’ tab of the financial gap analysis document.
c) General notes:
a. Swaziland's fiscal year starts in April and ends in March the following year. For
this exercise, "2012" represents "April 2012-March 2013". Therefore, "2017"
represents "April 2017-March 2018" (the last quarter not covered by NFM grant
period of calendar year 2015-2017).
b. Major partners in each disease program were approached individually and
requested to sign off on the financial commitments for their respective
organisations.
c. The Ministry of Finance has reviewed the underlying assumptions for the
government commitments and willingness-to-pay figures.
d. The Financial Gap analysis was also presented to the CNDT and CCM at various
points and their comments were noted, discussed and appropriate changes were
made as requested by the CNDT/CCM members.
Costing of the HIV NOP/TB NSP:
The total cost of the eNSF and TB NSP has been calculated by leveraging the NSPs of
Swaziland TB and HIV Concept Note
04Nov 2014│ 36
the respective disease programs. Both the HIV and TB program undertook an extensive
exercise to develop their NOPs and costed each of the activities within the NOPs to
determine the full cost of the national response per disease area.
HIV NOP cost for the three years (2015-2018) is US$338,172,296.76 which is expected
to be covered from the government and stakeholders, notably PEPFAR and the Global
Fund. The government (using revenues and WB loan) followed by PEPFAR, the GF and
other stakeholders is the major source of funding. For further details, refer to the
Financial Gap Analysis and Counterpart Financing Table.
The total cost for NSP TB (2015-2019) is US$101 million where as the cost for 2014 was
calculated to be $26,058,104. However, the TB program was unable to implement all
the 2014 activities in the current year due to lack of sufficient funding from all available
sources. As a result, approximately $11M worth of activities that were originally
planned for 2014 will now be implemented in 2015 and 2016. The financial gap
analysis, therefore, shows the updated NSP cost for 2014 (adjusted for the $11M) as
well as 2015 and 2016, which incorporate 50% each of the 2014 activities. Note that the
overall gap and cost of the NSP for the 4 years remains the same (refer to Financial Gap
Analysis and Counterpart Financing Table).
Domestic Resources:
All figures are derived from Swaziland's Budgets Estimates Book. For total government
health funds:
1. FY 2011/12 to FY2012/13 reflect actuals
2. FY 2013/14 to FY 2016/17 reflect estimates
3. FY 2017/18 represents assumptions on average growth rate based on FY 2015 to FY
2017.
Note: Both HIV and TB specific data is obtained from Swaziland's 2013 Ministry of
Health Resource Mapping Tool. The tool breaks down total government Health Funds
by program area.
1. FY 2012/13 and FY 2013/14 were obtained from Resource Mapping data
2. FY 2014 /15 to FY 2017/18 assumes HIV and TB growth at the same rate as the
average growth rate for government health resources.
The HIV program includes significant resources from the government that support the
OVC program. The OVC resources leveraged the NASA data from FY 2010/11 and
assumed a 3% YOY increase till FY 2017/18.
The HIV and TB loan data for FY 2012/13 to FY 14/15 was provided by the government
while data for FY 15/16 to FY 17/18 was provided directly by World Bank. The World
Bank provided total estimates of the WB loan as well as the EU grant, which have a
ratio of 51:49 respectively (i.e. 51% of the total figures are part of the loan and are
reflected in the loan section – both for the HIV program as well as the TB program).
External Resources:
Most of the partner data for FY 12/13 and 13/14 are actuals derived from Ministry of
Health Resource Mapping Data. Future projections were provided by partners based on
one-to-one discussions. Note that the country assumed that any partner that has
historically contributed less than $1M based on Resource Mapping data would continue
the same level of support for future years. The programs requested all partners and
donors to notify the program if there are any significant changes in resources or
investment strategy. As noted in the section above, PEPFAR’s HIV investment strategy
has changed and the future commitments listed in the financial gap analysis reflect this
change as provided by the partner. As indicated above, the EU grant reflects 49% of the
total WB-EU commitment to the country.
Existing GF grants:
Swaziland TB and HIV Concept Note
04Nov 2014│ 37
The program leveraged available data for Global Fund’s budget period 14 through 25
covering January 1 2011 through March 31 2015 for the HIV grant to calculate the funds
committed by the Global Fund through the TFM process and Global Fund’s budget
period 3 to 14 covering April 1 2012 through March 31 2015 for the TB grant to calculate
the remaining disbursements till the end of FY 2014/15. Details of the data are
available on the ‘GF Grants’ tab in the ‘Financial Gap Analysis’ template.
Overall – Health Sector Spending:
The overall health expenditures as provided by the Ministry of Finance include
recurrent costs as well as capital costs by the government. Capital expenses for FY
2015/16 to FY 2017/18 were assumed to increase by 21% CAGR. Overall, the spending
on the health sector will increase at an average rate of 6.27% YOY for the next 3 years.
SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND
This section details the request for funding and outlines how the investment is strategically targeted
to achieve greater impact on the diseases and health systems. While the investments for both the HIV
and TB programs should be described, the applicant should also provide information on the expected
impact and efficiencies achieved from planned joint programming for the two diseases including
cross-cutting health systems strengthening as relevant.
3.1 Programmatic Gap Analysis
A programmatic gap analysis should be conducted for the six to twelve priority modules within the
applicant’s funding request. These modules should appropriately reflect the two separate disease
programs in addition to cross-cutting modules for both programs such as Health System and
Community Systems Strengthening.
Complete a programmatic gap table (Table 2) for the quantifiable priority modules within the
applicant’s funding request. Ensure that the coverage levels for the priority modules selected are
consistent with the coverage targets in section D of the modular template (Table 3).
For any selected priority modules that are difficult to quantify (i.e. not service delivery modules),
explain the gaps, the types of activities in place, the populations or groups involved, and the current
funding sources and gaps in the narrative section below.
The following modules will not be described in this session as the programmatic gap table
provides details in terms of coverage in quantitative terms. Please refer for each to the
relevant file and section;






Prevention programs for general population
PMTCT
Treatment care and support
TB care and Prevention
MDR/TB
TB/HIV
--------------- ------------ ---------------- ------------ ---------- ------------ ---------------- ------Health Systems Strengthening (HSS)
(a) Health Information Systems and M&E
Monitoring and reporting on national progress in health outcomes and performance
including for AIDS, TB, and Malaria is a key function of the government. This includes
reporting to the Global Fund, PEPFAR, and other key stakeholders. Over the years,
Swaziland has received support from PEPFAR, the GF, the UN system and other
stakeholders to strengthen HMIS capacity. Notwithstanding the achievements made in this
area, there are still gaps in the system including lack of a standardized registration and
tracking system, duplication of data, delays in reporting and weak harmonization of tools.
To address these, a new client management information system (CMIS) designed to
capture client information at service exit on key indicators is being piloted. This will serve
Swaziland TB and HIV Concept Note
04Nov 2014│ 38
to integrate and coordinate patient care for the three diseases and other key health
programs such as NCDs and Maternal Neonatal & Child Health. Currently, the system is
being piloted in 47 facilities through PEPFAR funding; and there are plans to roll it out to
the remaining 240 health facilities. Once fully implemented, it is expected to achieve 90%
timeliness of report submission, 90% completeness, and 95% accuracy of data by 2018.
To run the system, WAN and LAN installation and computers with servers are required.
The Global Fund is requested to support: 1) Networking and hardware/peripherals per site.
2) Additional 91 sites for LAN and 128 sites for WAN so that all 138 public health facilities
are fully connected/networked. These activities are to be covered within the allocation
funding. Other activities that need GF support are training of technicians and technical
assistance for monitoring and maintenance by computer services institutions. This request
is planned for above allocation funding.
For an efficient running of the unit the national office needs four additional senior M&E
Analysts government position Level E3, one for central and one each for the three regions.
The funding request is for 4 Senior M&E Analysts to capacitate the M&E Unit in the
allocation. As per the absorption plan of donor funded positions (2013), the government is
absorbing 10 positions over the course of 2013-2016, and the 4 positions will serve to
capacitate and provide oversight to those positions in the M&E Unit. In the long term,
these posts will be discontinued, as the primary purpose of these positions is to build the
capacity of the unit over the medium term after which the unit will be fully functional and
well positioned to fill positions according to its existing structure.
(b) Procurement and Supply Chain Management:
The main gaps in the PSM are largely related to storage capacity and systems management.
The projected increase in service expansion and demand for HIV, TB and Malaria services
and products will put additional pressure on the already strained health supply system.
Currently, there are three functional warehouses, which store and distribute health
products throughout the country. The required storage capacity for each is listed below;



Central Medical Store Facility: for general medical supplies, with 2,800m2 purpose
built storage space, however, its current requirement is 7,000m2.
ART Warehouse: The rented warehouse with a capacity of 5,300m2 currently stores
HIV/ART products, Malaria Nets, and Pharmaceuticals bulk products, however, lack of
shelving in this warehouse inhibits adequate storage of medicines and lab products.
National Laboratory Warehouse: Has a storage capacity of only 30m3, insufficient
storage space has resulted in inappropriate storage of commodities (e.g. storage in
corridors and bathrooms).
However, the current storage and management capacity does not match the demand and
the above requirements. Thus, there is a need to expand storage capacity of warehouses,
and to build capacity in procurement and logistics management, quality control, and
transport and distribution mechanism. To address this, a draft Warehousing and
Distribution Integration Plan is being finalized (Draft Sept 2014). The MOH has evaluated
options on whether to buy a warehouse or build a new one on the site of the current central
warehouse, and is awaiting decisions from the ministries that finance and manage public
projects. As construction of the new warehouse is expected to take time, there is a need to
refurbish existing ones, and enhance procurement and management capacity. The
refurbishment will focus on shelving, networking, partitioning, furnishing and air
conditioning of an existing structure. And the capacity building will focus on training
central and regional and facility based staff on requisitioning, storage and distribution of
essential medicines. The request for the Global Fund, thus, is to support this component
which will be funded from within allocation.
(c) Service Delivery:
The current plan is to implement the EHCP at all public, private and mission hospitals,
Swaziland TB and HIV Concept Note
04Nov 2014│ 39
clinics and health centres which account for 146 of the 287 facilities. However, there are
challenges that impede the process; namely;



Health facilities are not offering the package according to their level of care.
Key infrastructure and equipment are not available as expected.
There is no standard method of measuring and monitoring quality of care given.
Thus, implementation of the EHCP requires investments in infrastructure, equipment,
human resources and capacity building. The government has committed to gradually
address staff shortages in facilities through recruitment of additional personnel, training of
relevant cadres, and through task shifting of existing staff (see below in d) Health
Workforce). As part of this process, the MOH has costed the initial investments for
provision of essential health care services. It has also conducted a study on the situation of
infrastructure and equipment in 17 selected health facilities. The findings show that all
facilities need refurbishing or renovating (gap analysis on infrastructure and equipment
2013). Based on the findings, currently MOH through the loan from the World Bank will
rehabilitate the maternity units at the National referral hospital and all health centres,
Operating Theatres will also be constructed in three health centers. In the initial TB/HIV
project plan there was also a plan to renovate some 24 primary health care facilities, this
however will no longer possible anymore under the TB/HIV after the midterm review of
the project due to funding constraints project critical need to rehabilitate the primary
health care still remains a priority.
The required GF funding is for refurbishment of 18 high volume facilities across the
country with 10 facilities included in the allocated amount and the remaining 10 in the
unallocated amount. The funding will cover programmatic gap from the MOH and EU/WB
grant and loan for the TB/HIV project.
(d) Health Workforce:
In 2012, Swaziland developed and costed its first Human Resources for the Health
Strategic plan (2012-2017). This plan provided a much-needed framework to develop and
retain human resources critical to the delivery of quality health services. As part of
implementation of the HRH strategic plan, a human resources work operational plan was
developed. The plan identifies, among others, recruitment and retention, training, and
management as key priorities.
As per the plan, general and specialized training for different categories of health
professionals will be organized in addition to technical support at workplace in the form of
supportive supervision and mentorship for staff (HR workplan 2o14). At community level,
a network of primary health workers play a critical role in enhancing the reach, uptake and
quality of HIV, TB and Malaria services, and retention in care of people affected by these
diseases. This network includes approximately 5,000 community-based Rural Health
Motivators (RHMs) that focus on demand creation as well as ensuring early identification
of illness. Recognizing this, the HRH plan emphasizes on training and re-training of these
community health workers health workers in an integrated TB and HIV management with
a curriculum that also incorporates essential maternal and child health skill building.
Functionally, the public health system is decentralized from the central MOH to four
Regional Health Offices (RHO), which are responsible to implement national health
policies and plans. The HRH plan aims to address gaps in management and leadership
capacity at a facility and regional level through continuing medical and professional
development for key cadres and regional managerial staff. Additionally, the HRH Plan also
recognizes a need for improved continuous formal induction to ensure significant cost
savings by ensuring that new employees have the training they require in policies and
procedures so that they can undertake their role effectively. The MOH is currently
investing its sources and receiving financial and technical support from other partners to
train clinical and public health personnel. However, there are funding gaps for training and
induction for the workforce. Thus, the request for the GF is to support training of
administrators, to conduct orientation workshops, as well as training of community and
facility-based primary healthcare workers.
Swaziland TB and HIV Concept Note
04Nov 2014│ 40
Community Systems Strengthening
Within Allocation
Community Systems Strengthening (CSS) gained momentum in recent years and it has
become increasingly clear that community support for health and social welfare has unique
advantages. The eNSF recognizes that CSS tends to be wrongly conceptualized and its
implementation limited to thematic areas, hence losing its value.
A number of institutions that include 120 NGOs, CBOs and FBOs provide services to all the
360 communities including 298 out of 320 communities have KaGogo Social Centres
(KSCs), 37 out of 40 towns/wards have Social centres in urban areas and over 1,550
Neighbourhood Care Points (NCPs). Service provision to these communities has been
integrated in the different modules as part of community interventions. However, the
advancement of gender equity and equality, enabling environment and empowerment for
advocacy has been hampered by weak coordination of actors, including community groups
and networks. There is vertical implementation and uncoordinated service delivery at
community level which emanates from lack of clear mandates, roles and responsibilities for
the different structures. Integration of health and community systems, for instance
TB/HIV and RMNCH has culminated in the duplication of services and underutilization.
This is, exacerbated by the absence of a harmonized volunteer policy (SRHR Advocacy
Strategy 1024-2017). Inadequate understanding of the systems by communities, in
particular the potential to effectively use community-based structures and systems that
have been put in place is common.
Community and health systems synergies are important as they both address access and
uptake, adherence and retention to care hence the need to harmonize both systems along
the six building blocks.
Swaziland has carried out several capacity assessments for community service delivery
which have shown capacity inadequacies, low technical skills, human resources to deliver
the services and availability of equipment. In 2010 NERCHA facilitated the development of
a Technical Support plan in response to the capacity gaps. This plan is used to support the
coordinated delivery of technical support to address the gaps and accelerate the
implementation of the response. The plan is not fully operational due to funding gaps. .
Table 2 Summary of community services and plans for scaling up
Current CSS activities
HIV/TB programs: mobilization, health
education, treatment and adherence
support; and follow up program
services.
Monitoring
for
accountability:
communities monitor and report to
different
projects;
no
standard
reporting format, no follow up and feed
back to communities and facilities.
Mobilisation
and
coordination:
Currently stakeholders use nonstandardized curriculum; coordination
is limited and service delivery is
fragmented. No incentives to retain
community volunteers.
Building institutional capacity for
leadership, resource mobilization and
program management by stakeholders
with little focus on systems building.
Gaps in CSS
Lack of guidelines on community
engagements in particular related to
health services.
Planned scale up activities
Integrate services and ensure better
coordination among community actors
and link to health systems.
Poor
referral
linkages
from
community to the health facility level
(data flow).
Lack of monitoring/reporting of
health care services
Lack of framework on community
systems
Limited
coordination
between
different actors / structures.
Limited implementation of policies
and strategies.
Lack of standardised service packages
at community level.
Leadership, governance, M and E,
Financial and grant management and
technical capacity weaknesses at CSO
level
Adapt a harmonised monitoring and
reporting system with clear linkages to
health facilities, national level and
partners (data flow chart).
Develop a CSS framework and
operational plan that defines task and
responsibilities; integrated training
curriculum.
Scale up IGAs and incentives for
community volunteers to sustain their
work
Develop standard guidelines, manuals
and train CSO, FBO CBO in essential
skills for leadership and management.
Sensitize community leaders for
improved ownership of CSS.
The Global Fund request is to strengthen community mobilization, coordination, referrals
and linkages, building capacity for monitoring of services delivered at community level.
Swaziland TB and HIV Concept Note
04Nov 2014│ 41
Moreover, to ensure sustainability of community systems, there is a need to impart
economic strengthening (small business) skills, link them to saving/credit and revolving
fund schemes, which is included in the request to Global Fund. This is all within the
allocated amount.
3.2 Applicant Funding Request
Provide a strategic overview of the applicant’s funding request for TB and HIV,
including both the proposed investment of the allocation amount and the request
above this amount. Include the specific elements related to joint programming such as
health systems and community systems strengthening. Describe how the request
addresses the gaps and constraints described in sections 1, 2 and 3.1.If the Global Fund is
supporting existing programs, explain how they will be adapted to maximize impact.
3.2.1. HIV Program
3.2.1.1. Prevention
Within Allocation
HIV testing and counselling (HTC)
HTC is the gateway to prevention and treatment and care programs. The goal of the HTC
program is to test all men, women and children for HIV in order to support rollout of ART
for life. The country has recently identified the need to review the HTC targets in the eNSF
to be able to achieve the goal of reaching universal testing and ensuring the achievement
of the treatment targets. In line with this, the targets in the eNSF will be revised to reach
80% of the population by 2018. However, it is not possible to do this prior to submission
of the concept note as the revised targets have to be presented and approved by the
Ministry of Health and other stakeholders. At this point in time, the concept note includes
indicative target for HTC which are pending review and approval by the Ministry of Health
and stakeholders. Thus, the review of the targets will be formalized in the annual or
midterm review of the eNSF in 2015. Nevertheless, the Ministry of Health will commit to
provide sufficient funding to address the new gap that results from the higher targets. The
Ministry of Health is already looking at improving efficiencies which includes changing
the approach used for training i.e. use of on-job training as opposed to residential training.
The HTC program will prioritize targeting 0-5 year olds, young girls between 18-24 years,
men between 24-40 years, most-at-risk populations (MSM, sex workers and prisoners,
which will be informed by the population size estimate survey which is currently ongoing
funded by PEPFAR). The Ministry of Health will continue resource mobilization to cover
the new financial gap. The HTC program has been meeting the testing needs of the ART
program through the Provider initiated HTC approach, which targets all clients attending
health facilities. Moving forward the HTC program is looking into innovative ways to
reach the population of patients who do not attend health facilities and are not reached
through the regular PIHTC and CIHTC approaches in order to reach the 2018 target. This
includes an expansion of the community based testing activities and intensifying efforts to
address barriers, integration of services, increased demand creation, and strengthening
referral and linkages.
Key activities to increase availability and uptake of HTC services include demand creation
Swaziland TB and HIV Concept Note
04Nov 2014│ 42
using innovative approaches such as door- to-door counselling and testing, mobile-testing
units, outreach services (bus rank, chiefdoms and dip tanks), national HTC campaigns (i.e.
the “month of testing”). These will be complemented by risk reduction counselling in
multiple and concurrent partnerships, intergenerational sex, unprotected sex and other
risk behaviours such as anal sex. PLHIV will be regularly counselled and encouraged to
bring their partners for testing and to disclose their status.
This component is fully funded from government and PEPFAR sources, and as such there
is no funding gap and thus no request is made for GF funding.
Within Allocation
Social and behavioural change
The SBC strategy (2009-2014) was developed to guide implementing partners in the
design of social and behaviour change interventions that is currently on use. Nevertheless,
the joint review of the NSF revealed that there are numerous but fragmented SBC
activities, which have not achieved the scale and coverage required in achieving the
desired goals. There is limited standardization in approach with most interventions are
implemented in an ad hoc manner without sufficient intensity or focus. The need to
develop a standardized prevention package that guides delivery of SBC interventions that
draws from evidence and models that have been evaluated and found to be effective in the
region has been identified.
Accordingly Global Fund support is requested for the development of a structured
prevention package which draws from the HIV prevention toolkit, the Community
Capacity Enhancement (CCE) model, the “Stepping Stones” model. The prevention
package will comprise structured step-by-step sessions with repeat exposure and in-depth
information on HIV, a simplified facilitator’s booklet for all the prevention areas (key
population, MC, Condom, PMTCT, GBV and PEP).
The expected benefits of this package are that, the target populations will 1) increase
personal perception of HIV risk and provide in-depth information on HIV, teenage
pregnancy, gender-based violence, and sexually transmitted diseases and other prevention
services; 2) be exposed to information that will guide them to make informed decisions
and choices and 3) gain social skills that will contribute to the development of positive
self-worth, assertiveness and confidence, especially to resist negative peer pressure.
The eNSF refocused for the SBC interventions are selected based on high incidence and
high prevalence to address both transmission and acquisition. As cited elsewhere (section
1), these include men, girls, school and out of school youth and young women, sex
workers, migrant/mobile populations and MSM.
The focus for men (ages 25-45) includes messages on HTC and referral to health services,
early uptake of treatment, TB, HIV risk perception, gender issues, counselling, condom
use and MC. To achieve high level of coverage of SBC services, interventions will focus on
areas where men congregate which are the dip tanks, sugar belt industry, factories,
Matsapha (hot spot), churches, municipality meetings, trucking transport industry and
soccer.
The focus for in and out of schoolgirls and young women between ages 15-19 will include
sexuality education, risk perception, GBV, condom negotiation and use, HTC and referral
to health and SRH services. This intervention will target schools, churches, textile
industries and communities in order to achieve high-level coverage.
Swaziland TB and HIV Concept Note
04Nov 2014│ 43
Currently, the government has rolled out national mass media and community-based
campaigns; UNFPA is supporting SRH dialogues targeting young people in Shiselweni
region; UNICEF and UNESCO supports life skills and SRH in 25 schools. PEPFAR is
supporting SBC interventions targeting adolescents and young women, adult males, MSM,
and sex workers in hot spot areas in all the 4 regions. To scale up HIV services, among the
transport, sugar industries and factories, the workplace existing service providers to
promote uptake of services will be utilized. This will complement the MC “ask” for mobile
services to ensure comprehensive health services for men in other catchment areas.
Within Allocation Request
The Global Fund is requested to support scale up of the structured HIV Prevention
package amongst men, women and girls (targets described above). The content and
approach of this will be informed by the HIV Prevention Toolkit, the piloted life skills
modules, the girl and boy empowerment movement model (GEM /BEM) as well as the
VPE and Stepping Stone modules that have proven to work in other countries. This will be
done through 1) identifying team members to be prevention and treatment champions for
the 16 premiere league soccer teams (5 per team, including the coach), providing
mentoring and coaching for them to promote and mobilise men among the football
fraternity for improved male involvement and service uptake. 2) Recruitment (at $113 per
month) and training of 548 (255 volunteers 1 per school and 293 volunteers 1 per
community to facilitate the structured 18 session curricula in 255 secondary high schools
and 293 communities within the three years. This training is a five-day training to create
cohesion, peer support and standardization in the delivering of the intervention. 3) Half a
day orientation for 255 teachers (1 teacher per school) to form a sustainable support
system for the in school sessions where the teacher will be the entry point for the peer
educator into the classrooms. 4) Buying space in social platforms using electronic/mobile
technologies in a form of (1 message a month) 5) paying for mass media in a form of 48
radio programmes (4 per month) broadcasted through Swaziland Broadcasting and
Information Services (SBIS) and the Voice of the Church 6) developing three dramas to be
broadcasted in the three years to further re-enforce messages thus utilising innovative
theatre for development 7) development and printing of the information and education
package (as described in section 1.3) to be used in the intervention and 8) engagement
through providing travel and subsistence allowances, fuel and related costs for existing
outreach mobile clinics to scale up HIV services and ensure comprehensive health services
to increase coverage for all target groups.
Out of school sessions will be organized in conjunction with other recreational activities
and mobile health services.
All target groups will be reached through the existing structures (at national, schools,
workplaces and communities), social platforms using electronic/mobile technologies in a
form of (1 message a month), mass media in a form of 48 radio programmes (4 per month)
broadcasted through Swaziland Broadcasting and Information Services (SBIS) and the
Voice of the Church). In addition, edutainment through three dramas will be done and
broadcasted in the three years to further re-enforce messages thus utilising innovative
theatre for development.
Ten implementers (CSOs and FBOs) will be allocated 30 communities each to monitor and
follow through the implementation of the structured prevention package for the out of
school. In 255 schools, 7 selected CSOs supervised by the Ministry Of Education will be
tasked to monitor and follow through the implementation of the structured prevention
Swaziland TB and HIV Concept Note
04Nov 2014│ 44
package in schools. The national coordinating entity will oversee the coordination of these
interventions
This is expected to increase personal risk perceptions, improve the adoption of safe sexual
behaviours and increase uptake of services.
Condoms promotion and distribution
Within Allocation
National coverage for condoms is estimated at 41.2 % (PSI Swaziland, 2010). This reflects
a need to address geographic distribution to ensure full condom coverage is achieved.
Targeted and equitable distribution and promotion also remains a gap.
The country embarked on a quantification exercise, which showed that the need for
condoms for the next three years is 14,7 million for 2015, 15,4 million for 2016 and 16
million for 2017 respectively (Swaziland Report on Quantification of Family Planning
Commodities 2014-2018). PEPFAR has allocated a budget of USD 1 million for procurement
and promotion of condoms for youth and key populations. AIDS Health Care Foundation
(AHF) has committed to procuring 4.4 million condoms annually over the next 3 years.
UNFPA has since ceased to support the country with condoms and this has led to a 10
million gap in condoms. Global Fund is therefore requested to support the purchase of 10
million condoms per year within the allocation.
Within Allocation
Global Fund support is requested to purchase and install 13 dispensing machine to ensure
24 hours condom availability in strategic locations. These sites include two in Mbabane, 3
in Matsapha, One at the University Matsapha campus and 3 in Manzini City, 1 n
Nhlangano, 1 Lavumisa, 1 Zulwini and one Gabbles (Hot Spots). The Municipalities will
manage the use and refills of this machine. The country is also requesting support to
purchase 600 branded bags (inscribed with prevention minimum package messages) to
facilitate community level condom distribution using volunteers commissioned and
supervised by the an allocated service providers delivering the structured prevention
package at community level. This request will contribute to the increase in condom
coverage from 41.2% to 80% by 2017, as it complements other condom distribution
networks. Support for orientation sessions to create cohesion in distribution and
messaging and peer support for these distributors is also requested. All the above requests
are within the allocated amount.
Prevention of Mother to Child Transmission
Within Allocation
Whilst the PMTCT program has achieved tremendous success in reducing new infections
among exposed infants (from 19.6% in 2009 to 11% in 2012) infant sero-conversion post 8
weeks remains a challenge as a result of loss to follow up of mother-baby pairs and poor
breastfeeding practices. Swaziland will accelerate the roll out of option B+ (Swaziland
Phased Roll out of Option B+, 2014), which is the provision of ART regardless of CD4 and
WHO stage to all pregnant and lactating women. This approach will address Prong 3 and
4. Prong 1 is addressed under structured prevention package (as outlined in section 1.3.).
In addition, communities will be mobilised to support PMTCT clients and in particular
encourage men’s involvement in PMTCT interventions (see SBC strategy for men).
Swaziland TB and HIV Concept Note
04Nov 2014│ 45
Currently, government and UNFPA procure FP commodities. PEPFAR supports provision
of comprehensive PMTCT services including clinical mentorship, psychosocial support
and adherence counselling and community engagement using PMTCT as an entry point
for service uptake and follow up of children as part of a broader community prevention
response. In the Shiselweni region MSF collaborates with PEPFAR partners in the
provision of comprehensive PMTCT services and implementation of Option B+ in 9
facilities. EGPAF and ICAP have been supporting the MOH in integrating FP services
within ART/MNCH service delivery points.
The national PMTCT program data shows that only 3% of children born to HIV positive
mothers are infected with HIV at ages 6-8 weeks. To improve performance of the program,
the country will accelerate the roll out of option B+ (Swaziland Phased Roll out of Option
B+, 2014), to all pregnant and lactating women in in order to strengthen the PMTCT
program. However, follow-up of mother baby pairs and ART adherence of pregnant HIV
positive women has historically been a challenge, which has resulted in new infections
among children at a rate of 10.4% post 8 weeks. This is due to breast-feeding practices,
loss to follow up post the 8 weeks and low uptake of ART among eligible mothers.
Expert clients are used at community level to intensify mother-baby pair follow up and
provide psychosocial support to pregnant and lactating HIV positive mothers which aims
to address the challenge of follow up of mother-child pairs post 8 weeks. This intervention
is targeted at reducing Mother to child transmission (MTCT) of HIV beyond 6-8 weeks by
promptly identifying infected mothers and their children to refer and retain them to care
and treatment services.
Currently 60 communities out of 360 are covered by this intervention. Complementing the
family focused and centred approaches, community cadres and structures including
RHMs, support groups and health committees and expert clients identify pregnant and
lactating mothers, refer them to services using the Facility-Community referral tool, track
and follow them up to provide support for disclosure, nutrition education, adherence
counselling and family planning. This will be complemented by the provision of mobile
HIV/SRH services articulated under the SBC section.
Global Fund support is requested for recruitment, orientation and deployment of an
additional 300 expert clients to cover the 360 communities in Swaziland. This request is
within the allocation amount. Facility based expert clients reach approximately 10 women
per day and community based expert clients conduct 10 household visits per week to
identify pregnant and lactating mothers.
The expected impact of this intervention is the provision of continuum of care post 8
weeks i.e. more mothers will be retained in care, will impact maternal mortality, HIV
transmission to infants will be reduced and HIV positive children will be identified and
linked to care.
Voluntary Medical Male Circumcision
Within Allocation
The new 5 year Strategic and Operational Plan for MC has refocused the MC program
based on the epidemic, the revised model for MC (Decision Makers Program Planning
Tool v2.0 (DMPPTv2.0Model), as well as lessons learnt from the past five years. The new
strategy provides coverage targets for specific age groups at national regional and
Inkhundla level has shown that for high impact at lower cost, MC efforts in Swaziland
Swaziland TB and HIV Concept Note
04Nov 2014│ 46
should focus on the 10-29 year olds as primary target audience and 30-35 year olds as a
secondary target audience. Older men will not be excluded and in fact are an important
secondary target audience as they are important influencers for the uptake of MC by
younger men. There remains a gap in support in this area and support for the engagement
of key opinion leaders in creating a conducive environment for uptake of services as well
as supporting promotion of uptake of service. Chiefs, politicians, church leaders and youth
community leaders as well as CHIMSHACCCs and REMSHACCs will be targeted through
existing structures and will be provided with in-depth information on MC and progress
towards coverage levels in their specific constituencies.
The government aims at increasing circumcision from 38% in 2014 to 70% by 2018.
Access to VMMC services will be enhanced through decentralization of services so that it is
offered through outreach services and special campaigns targeting schools. Moreover,
community and health systems strengthening activities will be carried out so that they are
capable of coping with the scale up of MC services, including capacity building for the CMS
to improve supply chain management and strengthening of HMIS to be able to monitor
and evaluate MC interventions.
Currently, PEPFAR is committed to support scale up of high quality comprehensive MC
services through a mixed service delivery model that includes mobile, outreach and
support for integrating MC into existing health services, School targeted campaigns, and
active demand creation within communities and existing structures, will be intensified to
assure uptake of services.
Within Allocation
The statistics show that static sites show very low uptake of services whereas the mobile
outreach and campaigns have demonstrated much higher numbers for MC. By September
2014, the number of men circumcised in static sites reached 2,423 whilst mobile
outreached yielded a number of 7,445 circumcisions, reaching 10,557 of the 12,000, 2014
target. The outreach model is effective, however, experience has shown that to get men
into services requires enormous efforts to transport men to the services or to bring
services closer to men and this remains a funding gap. Whilst PEPFAR support will
provide substantial support for adolescent and adult male circumcision promotion and
service delivery, however the issue of transporting men remains a major challenge.
The GF request is therefore requested to augment the delivery of comprehensive VMMC
through support for procurement of mobile clinics for use in outreach efforts. In addition
to MC services, the mobile clinics will provide comprehensive health-care for men
including condom distribution, HTC and ART referrals. GF is also requested to support
male-targeted demand creation for VMMC through community soccer teams. The
requested support will augment PEPFAR support, which will provide support for MC
teams on a quarterly basis who will provide the services.
Key Populations
Within Allocation
Customised prevention interventions targeting most-at-risk populations are limited. Key
populations currently prefer accessing services at specific service providers who have the
capacity to accommodate their specific needs. Given the prioritization of key populations
in the eNSF, the country will be improving the availability, access and utilization of
HIV prevention and treatment services for key populations. The MOH has
facilitated the development of a standardized service package for key populations
Swaziland TB and HIV Concept Note
04Nov 2014│ 47
which includes STI screening and treatment, HTC, TB screening, ART referrals, condom
and lubricant distribution, provision of comprehensive HIV information and treatment of
other ailments where relevant. Through PEPFAR support the country is currently
conducting a size estimation study that will inform targets for these populations. Whilst
baselines do not currently exist, a follow up BSS will be conducted to establish baselines.
These two initiatives will strengthen data and programming for key populations.
Within Allocation
In the next 5 years PEPFAR will provide funding for sensitization and training of law
enforcement officers, the population size estimate study, procurement and distribution of
lubricants and special condoms for key populations, peer education, mentorship, capacity
building for organisations representing key populations. PEPFAR in collaboration with the
Matsapha Town Board and other private sector partners will also fund a mobile health
unit in Matsapha Industrial area over the next 3 years which will provide health servies to
serve female factory workers, sex workers and other mobile populations residing in the
area. With a yearly target estimates of 1000 MSM and 1000 SW, and based on average 12
sexual encounters per month estimating two condoms and one lube sachet per encounter
1, 008,000 condoms and a 504,000 lubricants are estimated for use per year. These
requirements will continue to be funded by PEPFAR.Other partners such as MSF and
SWABCHA will be supporting mobile and static clinics which provide services to mobile
population sex workers and other key populations across the country. In 2014, a total of
344 MSM, 609 CSWs and 52 IDUs were reached through mobile clinic and six fixed
facilities (out of the 33 public facilities that have health workers trained). Currently only
33 out of the 138 public facilities have nurses who have been trained on providing
comprehensive services for key populations. Global fund is requested to support training
of 133 (one per facility) health care workers drawn from public health facilities to increase
the service points for key populations. The trained health care workers will be mentored
and supported by the Key Population Unit within the MOH.
The training of peer educators contributes immensely in reaching hidden populations
such as MSM and other key populations with limited access to HIV services. Peer
educators are also strategic in facilitating distribution of commodities and comprehensive
information to other key populations. Although support from PEPFAR covers the
provision of commodities for key populations, peer education training and deployment
remains a gap. Whilst the country does not have set standards for reach for peer
educators, program experience from organizations working with key populations has
shown that a peer educator can reach 8 people per week and approximately 416 per year.
Funding is therefore requested for the training of 400 peer educators among SW’s, MSM,
mobile populations (100MSM, 150 Sex workers and 150 mobile populations) The 400 peer
educators will use the prevention package to reach out to their peers and will reach
approximately 166,400 key populations. The amount is within allocation.
Gender based violence
Within Allocation
Gender based violence remains a challenge for HIV prevention in Swaziland. According to
National study on Violence Against Women in Swaziland (2007), one in three girls
experience sexual violence before the age of 18, and one in four women state that they
experience some form of physical violence during childhood.
There’s significant under reporting of incidences of gender based violence in the country.
According to the Vulnerability Assessment Committee Report (2007), more than half of all
incidents of child sexual violence go unreported and less than one in seven incidents
Swaziland TB and HIV Concept Note
04Nov 2014│ 48
results in female seeking help. There is also inconsistent mentoring support for
community GBV protectors. In addition, channels of reporting, referral and managing
GVB cases are still weak.
Swaziland is looking at strengthening national efforts to prevent and manage GBV. The
MOH in collaboration with the Ministry of Justice has adopted a national guideline and a
training manual for multisectoral response to GBV.
Currently, the government is upgraded the gender unit to a department for purposes of
financing. Further, a one-stop centre is being piloted for effective case management. A
community case management system has been put in place to identify and respond to
cases of child sexual violence. In addition, a domestic violence programme within the
Police has been institutionalised in 24 Police stations across the country. A multi-sectoral
national surveillance system is fully operational. A child friendly court has been
established at the High Court in Mbabane and the government has a plan to roll out to the
remaining 3 regions. Other partners are mainly involved in supporting the mainstreaming
of Gender into programming. These partners include PEPFAR, UN Agencies and Civil
Society Organisations.
The GF is requested to support a six month training of 11 nurses on forensic nursing, who
will be deployed to all the secondary and tertiary health facilities in the country (11) and
linked to the on-stop centre in Mbabane. These nurses will facilitate improved
management of cases, better collection of evidence and increased conviction of GBV
perpetrators. Funding is also requested to support community protectors forums targeting
586 (2 per community) over 3 years to cover the 293 communities where prevention
interventions will be implemented. This is to enhance coordination of their function,
accountability, problem solving and planning. Support is also requested for 879 Health
Community Days (HCDs) comprising of drama, information dissemination, role model
presentations and service provision covering all prevention interventions (SBC, MC,
PMTCT, GBV and Condom). One health community day per community per year will be
held over the 3 years. The amount being requested is within allocation.
Table 3 Funding request for priority strategies under prevention module
Swaziland TB and HIV Concept Note
04Nov 2014│ 49
Module
2015
2016
2017
Total
478,859.68
813,315.42
191,475.92
1,483,651.02
43,236.00
45,683.00
46,438.00
135,357.00
Prevention programs for sex workers and
their clients
33,386.00
53,236.00
33,386.00
120,008.00
Prevention programs for other vulnerable
populations (please specify)
33,386.00
33,387.00
56,503.00
123,276.00
Prevention programs for adolescents and
youth, in and out of school
536,431.00
426,641.40
391,641.40
1,354,713.80
PMTCT
214,632.00
214,632.00
214,632.00
643,896.00
16.7%
1,339,930.68
1,586,894.82
934,076.32
3,860,901.8
2
100%
Prevention programs for general population
Prevention programs for MSM and TGs
Total
% Funding
38.4%
3.5%
3.1%
3.2%
35.1%
3.2.1.2. Anti-retroviral therapy (ART)
Within Allocation
Provide ART for PLHIV across all delivery channels
Swaziland has adopted the 2013 WHO Consolidated HIV Guidelines. As per this guideline,
patients with CD4 cell count <500cell/mm3, and all HIV positive pregnant and lactating
women, HBV co-infected patients, HIV-TB co-infected patients, patients with HIV
associated nephropathy and the positive partner in a sero-discordant relationship will be
on ART. This requires improving capacity of the health system, including human
resources, increased drugs needs, increased laboratory needs, and more space within
facilities to cope with the increased demand for services. Currently, Option B+ for
pregnant and lactating women is being piloted in 19 facilities, but initiation of ART for the
other eligible populations as per the new guideline is scheduled for early 2015. Both
Option B+ and the expansion of ART to the other population groups in line with the new
WHO guideline will be rolled out in a phased approach: first covering the 133 facilities
already providing ART services using the old criteria, and then this will be expanded to all
the 183 ANC facilities.5
Currently the country enrols an average of 15,000 new patients on ART per year (Annual
ART report, 2011 and 2012; Annual HIV report 2013). This figure has been increasing
steadily over the last 3 years. Between January and June 2014 just over 10,000 new
patients have been initiated on ART. With implementation of Option B+ and the new ART
eligibility criteria (CD4<500), it is expected that at least 36,000 clients will be initiated on
ART by the end of 2015. This is a modest estimate considering that the number of people
on ART increased by 45% a year after increasing the ART initiation threshold from 200
cells/mm3 to 350cells/mm3 in 2010.
Swaziland TB and HIV Concept Note
04Nov 2014│ 50
Coping with the increased demand for services requires upgrading of service delivery at
the facility level. Training is a key component of this process. Swaziland has used the basic
IMAI training and Nurse led ART Initiation in Swaziland (NARTIS) to facilitate
decentralization of comprehensive HIV services. This training allows nurses to prescribe
ART (shifting this task from doctors to nurses), while being supported by consistent
mentoring systems from regional mentoring teams and doctors from hospitals and health
centres. A standardized NARTIS curriculum was developed to facilitate the rollout of these
trainings from the national level to the regional level for better training coverage. This will
enable the country to further decentralise comprehensive ART services to meet demand.
To facilitate the process of scale up, PEPFAR and MSF are supporting training and
deployment of ART mentors, development of a communication mobilization strategy, and
piloting of community based modalities to deliver ART services in the community. In
addition to improving access to services, this approach also improves adherence and
retention in care. Above and beyond what the National ART and PMTCT programs are
doing to meet these demands, the country through the World Bank has also sought
funding in the form of grants and loans to refurbish and expand high volume facilities to
improve service delivery (see 1.2, HSS Section). This support extends beyond
infrastructural improvements, as it will also seek to capacitate regional and facility health
managers.
To meet this rapid increase in the need for treatment, the government of Swaziland will
need to strengthen procurement and supply chain management, human resource capacity,
M&E and linkages with community systems. The government will continue to procure
ARVs for the population below 350cell/mm3. PEPFAR, MSF and other development
partners will continue to supporting treatment and care by strengthening health and
community systems related to ART service delivery.
The GF funding request is to procure all paediatric6 ARVS and 20% of the adult
population’s ARVs requirements (for the population above the current eligibility criteria).
This support will increase ART coverage from the current 101,730 PLHIV to target of
161,837 resulting in 75% ART coverage of all PLHIV by 2017. This scale up is in line with
the country’s goal of achieving the 90/90/90 UNAIDS targets. This funding request is
within the allocated amount.
Within Allocation
Strengthen procurement and supply management for drugs and related commodities
The National Molecular Reference Laboratory (NMRL) testing facility has the major
equipment (3 Roche COBAS platforms) to support the VL scale up. Viral load monitoring
will allow the county to diagnose treatment failure early and manage it appropriately. This
has an impact on the development of drug resistance and hopefully minimizes the number
of patients needing expensive and complicated second line regimens.
The government has demonstrated commitment in absorbing staff funded under the
Global Fund and other donor supported programmes, especially if these positions are
aligned to the civil service establishment register. It is also funding the bulk of laboratory
reagents but will not be able to support the costs related to rapid scale up of ART
provision.
6The
NARTIS training is the first step in capacitating health care workers at the primary care level. This
is followed by a structured mentoring and support supervision system, using regional mentors,
specialized nurses and doctors from the Baylor Center of Excellence and regional supervisors to
mentor and support nurses in the regions to provide ART services to children .
Swaziland TB and HIV Concept Note
04Nov 2014│ 51
PEPFAR is supporting the strengthening of the National Sample Transport System to
facilitate viral load scale up. It is also anticipated that other partners (PEPFAR/MSF) may
introduce point of care viral load monitoring in the next few years, which will also
decrease the burden on the NMRL. MSF is already providing routine viral load monitoring
in one administrative region in the country (Shiselweni) and this scale up will mostly cater
for the remaining 3 regions.
The country is requesting Global Fund to support:




Extension service contracts for the current instruments to keep it functional.
Procure centrifuges for primary health clinics (sample preparation and storage).
Recruitment and salaries for 5 additional laboratory technologists and a data clerk to
handle the load in volume of VL and EID tests. A combination of scaling CD4 testing,
implementation of a shift system for staff working in the molecular load and the
continued commitment by government to absorb staff (especially staff aligned to the
national establishment register) will see this intervention sustained beyond the
funding period (see government absorption plan and its performance over the
previous GF Grant. Not all staff requested here will be absorbed as testing will stabilize
after the initial rapid scale up and some efficiencies will be gained from the scaling
down of CD4 testing resulting in a decreased HR need in this area).
Global fund support is also requested in procurement of haematology and chemistry to
support the scale up of ART provision. Though the laboratory has embarked on a
process of re-establishment, this is ongoing and may impact the delivery of these
services during the course of the grant, but this process is still a long way from
completion and these services are not adequately funded. Global Fund support will
assist the country to monitor toxicities related to the ART medicines as the country
scales provision of ART. This is an essential component of ART sale up and will lead to
better patient outcomes and maintain delivery of quality ART services (Viral load task
force interim report, 2014).
Within Allocation
Conduct HIV Drug Resistance (HIVDR) Activities
HIV Drug Resistance (HIVDR) monitoring will be strengthened to generate evidence to
guide the response. Swaziland has adopted the new WHO guidance on HIVDR,
established a functional early Warning Indicator System, completed three sentinel
surveillance studies (Transmitted HIV drug resistance) and two acquired drug resistance
surveys. WHO continues to provide technical support along with other technical partners
(PEPFAR). PEPFAR will provide technical support in the form of USD 250,000 to aid this
process and may also provide some level of genotyping through its laboratory in Atlanta
(still to be confirmed).
The country is requesting Global Fund support costs of genotyping tests for future surveys.
These costs will cover about 260 participants per survey, with four surveys planned for the
period 2015 to 2017.
Above Allocation
Improve nutrition supplementation for PLHIV at health facility level
According to the Swaziland National Nutrition Council Survey (2010), 11% of clients
initiating ART and 33% of TB patients are malnourished and require nutritional support.
government implements nutrition assessment and counselling, and provides fortified food
to malnourished ART patients, TB-HIV co-infected patients, and pregnant and lactating
women.
Swaziland TB and HIV Concept Note
04Nov 2014│ 52
The Global Fund is requested to support the scale up of nutrition assessment, counselling
and provision of fortified food to malnourished patients from the 12 facilities currently
supported to all 133 health facilities currently providing comprehensive HIV services. This
number encompasses the 86 facility providing TB services (BMU).
This will enable government to reach its eNSF targets to improve the increase nutritional
support from 40% in 2013 to 65% in 2015 and 85% in 2018.
Within Allocation
Strengthen follow-up of HIV-exposed infants, and identify children with HIV
Children (7943 on ART) currently make up less than 10% of people on ART in the country,
based on spectrum estimates of children in need of ART this proportion should be
approximately 15%. Transmission at 6-8 weeks post-partum is at 3% but increases to
10.4% by 18 months. Identifying and initiating HIV positive children on ART is an
important activity for the country moving forward. Strengthening the follow up of motherbaby pairs will facilitate identification and enrolment into care of HIV positive children.
See the request under PMTCT to support mentor mothers and facilities with airtime to
follow-up these mother-baby pairs.
PEPFAR and Clinton Health Access Initiative (CHAI) are supporting government to set up
infant surveillance systems to track HIV exposed children that will be linked to the
national HMIS. They are providing financial and technical support.
Though identification of children is a challenge, government and other partners have
committed to address this area and other needs like EID test kits, NVP and cotrimoxazole
are covered by government. There is no further request beyond support for mother-baby
pairs highlighted under PMTCT.
Within Allocation
Strengthen community systems to enhance quality and provision of HIV services for
PLHIV including through continuation of nutrition support
Strengthening community systems to provide ART services is essential to the scale up of
ART provision. Community based interventions will help the country absorb the large
numbers of patients requiring ART. Currently MSF and ICAP are conducting pilots to
assess the acceptability and feasibility of specific modalities in the delivery of ART within
communities. There is no funding gap currently for this activity and hence no request for
global fund to support his activity.
Table 4: Funding request for priority strategies under treatment, care and support (ART)
Treatment Care and Support
Antiretroviral Therapy (ART)
2015
2016
2017
Total
4,016,342.00
4,886,365.00
5,397,956.00
14,300,663.0
0
6,392,290.00
8,688,642.00
9,844,252.00
24,925,184.0
0
Treatment monitoring
TOTAL
10,408,632.00
13,575,007.00
15,242,209.0
0
39,225,847.0
0
1,112,558.00
2,883,065.00
% Funding
36.5%
63.5%
100%
Above allocation request
Treatment adherence
Swaziland TB and HIV Concept Note
761,141.00
1,009,365.00
04Nov 2014│ 53
3.2.2. Tuberculosis
Swaziland has recorded significant progress in expanding access to TB diagnosis and
treatment through nationwide implementation of rapid molecular diagnostics,
decentralization of TB services, strengthening of community-based health services and the
National Sample Transportation System as well as engagement of all care providers
including private health practitioners as well as NGOs, CBOs and FBOs through the
Swaziland STOP-TB Partnership. Swaziland declared TB as a national emergency on 24
March 2010 and this enabled political will and commitment as well as providing a
conducive environment for technical assistance and support from implementing partners.
These critical enablers have been successful in laying the ground for the country to move
from passive case finding towards Active Case Finding which will entail systematic contact
tracing, in order to mitigate the challenges remaining with the declining TB case
notifications and treatment success below the international and NSP target, despite
improvements over the last 3 years. This underscored the prioritization of interventions to
increase early TB case detection and laboratory diagnosis as well as improvement of the
treatment success rate as envisioned in the current NSP.
Goals and objectives of the NFM funding request:
The main goal of this concept note is to contribute to the reduction of the TB, TB/HIV and
MDR-/XDR-TB burden in Swaziland in line with the national and global TB targets.
The strategic priorities for this concept note include addressing the declining TB case
notifications, expansion and strengthening of the TB laboratory network, timely initiation
of TB treatment, expanding access to integrated TB and HIV services through a one-stop
shop approach, strengthening programmatic management of Drug-Resistant tuberculosis
(PMDT) and optimizing the contribution of communities in TB care and control through
empowerment. The Programme Management and Health Information (M&E) system will
be strengthened as part of supportive health system environment to facilitate effective
programme implementation. These priorities fall under 3 core modules (Table 5).
Table 5: Breakdown of proposed investment by module
Module
TB Care and Prevention
Allocated
request (US$)
funding
Above allocated funding
request (US$)
Amount (US$)
%
79.3%
Amount (US$)
2,057,714.00
16.4%
18,670,362.00
7,288,467.00
%
58.0%
TB/HIV collaboration
1,221,904.00
5.2%
MDR-TB
3,644,550.00
15.5%
3,218,586.00
25.6%
TOTAL
23,536,816.00
100
12,564,767.00
100
TB Care and Prevention Module
Interventions proposed for funding under this module are meant to address the gaps in TB
case detection, diagnosis and treatment success. Successful implementation is expected to:
increase case detection and notification, increase coverage to TB diagnostic services for
adults and children; and increase treatment success rate. Enhanced childhood TB
diagnosis and management is expected to increase the proportion of children among
notified cases.
Swaziland TB and HIV Concept Note
04Nov 2014│ 54
Table 6: Anticipated cumulative coverage/impact with GF (TB Care and
Prevention)
Coverage indicator
Number of notified
cases of all forms of TB
(Bacteriologically
confirmed + clinically
diagnosed) New and
relapses
Investment
Baseline
Expected coverage/impact
2013
2015
2016
2017
6,665
8,162
9,819
10,634
Allocated
No baseline
6,530
7,855
8,507
Above allocated
No baseline
1,632
1,964
2,127
Above allocated +
Allocated +
No baseline
8,162
9,819
10,634
Assumptions: Current case detection is based on WHO estimates. This will be adjusted when
results of the proposed prevalence survey are released.
Prevention – Within allocation funding request
One of the key interventions to provide a robust implementation of TB Prevention is to
engage and empower communities by increasing national coverage and involvement of
communities at large, including community leaders and influential individuals. This
involves increasing community awareness and social mobilization activities by conducting
community campaigns, and strengthening the Public-Private Partnership coordination.
Community linkages and TB care delivery: The funding will support strengthening of
mechanisms for coordination of TB activities by CSOs. This will enable further utilization
of the full potential of the over 5,000 existing Rural Health Motivators (RHMs) trained
through the HSS grant, which can provide more services for integrated TB/HIV screening
and care. Retention of Treatment supporters, Adherence Officers and Cough Officers is
critical to ensure gains achieved in ongoing intensified case finding and contact tracing
activities are sustained. The main activities to be supported include implementation of the
Active Case Finding (ACF) strategy, Advocacy Communication and Social Mobilization
(ACSM) for demand creation, systematic TB contact investigation and Intensified Case
Finding (ICF), treatment adherence support, stigma prevention and retrieval of patients
lost to follow up. The existing ACSM strategy has been updated in line with the WHO
ENGAGE-TB approach. Annual TB day commemorations at national and regional levels
will be conducted as well as community awareness campaigns.
Engaging all care providers: The allocated funding will support development of training
materials, site assessments and training of private/alternative health practitioners and
pharmacists on TB case detection and management. Post training mentorship visits will be
conducted to support implementing sites.
Case detection and diagnosis – Within allocation funding request
Following the declaration of TB as a Public Health emergency in 2011, the country
experienced a continuous decline in case notifications against an upward trend of WHO
modelled estimates. This was despite extensive implementation of Intensified case finding
(ICF) in health care facilities and among high-risk populations (miners, prisoners, HCWs,
children and PLHIV). A KAP survey conducted in 2011 showed evidence of poor health
care seeking behaviour among the general population and that 85% of the population were
aware of the disease but that knowledge was not translated to early health seeking
behaviour at health facilities. Therefore, there is an identified and evidence-based need for
TB screening services to be expanded to the community level with strengthening of
linkages to care. This underscored the prioritization of the following interventions aimed
at expanding of ACF and ICF; strengthening childhood contact tracing, diagnosis and
Swaziland TB and HIV Concept Note
04Nov 2014│ 55
management; strengthening and expansion of the TB peripheral laboratory network to
ensure all facilities have access to GeneXpert MTB/RIF testing through the National
Sample Transportation System (NSTS); and improvement of access to quality radiological
services for enhanced diagnosis of childhood TB.
From the above identified priority interventions, it is evident that onsite community TB
services are critical to provide TB screening, onsite diagnosis and treatment initiation of
key populations, groups in congregate settings (especially miners and prisoners), underserved, hard to reach areas and TB hot-spots. For the successful implementation of active
TB case finding in these communities, funding under the NFM is requested to support
procurement of two mobile TB clinics, each fitted with a GeneXpert MTB/RIF machine
and digital Xray to facilitate optimal case detection and linkage to care. This support will
complement the 2 fixed digital X-ray machines in place procured under the current grant.
One mobile clinic will be used to conduct community campaigns in under-served, hard-toreach communities with a focus on enhancing radiological diagnosis of childhood TB as
well as outreach services to key populations, especially miners and ex-miners as this group
is most often marginalize and yet most-at-risk of dual TB and HIV infection. The second
unit will be used for the proposed TB prevalence survey and continued active case finding
among key populations and in congregate settings (miners and prisoners).
In addition, actively finding cases within the communities in homesteads is critical to
ensuring access to TB screening and testing services. To support this initiative, funding is
requested to recruit 369 Active Case Finders who will be based in each of the 369
chiefdoms to conduct door-to-door TB screening and testing with promotion of HIV
prevention and treatment services through the distribution of IEC materials and condoms
(male and female). Each of the 369 chiefdoms have approximately 300 homesteads which
house on average 10 people, therefore, bringing TB screening and testing services closer to
the people would enhance access to marginalized populations with very limited access to
health facilities due to cultural/religious barriers, stigma or fear of victimization. These
include but are not limited to women, children, PLHIV and MSM who may not be
comfortable with accessing TB and HIV services at facilities or during community
campaigns. Swaziland has made significant progress towards addressing the declining TB
case notification rate with the expansion of systematic screening in health facilities and
active case finding among high-risk populations. To further support these gains,
strengthening and expansion of ICF and systematic contact tracing in the 200 public
health facilities that have not yet been accredited as TB Basic Management Units (BMUs)
is a critical component of the country’s response to the TB/HIV co-epidemics. Although all
the public health facilities provide a minimum of TB screening services, under the current
arrangement, it is not routine or systematic (passive) due to very limited human resource
and an overburdened health system. Therefore, in order to improve systematic screening
and intensified case finding, funding is requested to support the existing 40 Cough
Officers and recruit an additional 160 to ensure coverage of all main entry points at the
health facilities for systematic screening and ICF integrated with Primary health clinics to
provide integrated services under one roof which include but not limited to EPI and minor
ailments for under-fives years, ART sites, NCD clinics, Antennal care (PMTCT/MNCH)
and family planning services. Some high volume health facilities with multiple entry
points, will require more than 1 cough officer to be stationed at that facility.
This funding request will support the retention of the existing 20 microscopists and 8 lab
technologists funded under the existing TB R10 grants well as laboratory consumables for
GeneXpert, culture and drug susceptibility testing (FLD and SLD) to ensure an
uninterrupted supply of diagnostic commodities. A total of 230,400 GeneXpert cartridges
will be procured to support diagnostic services over the next 2 years during the scale up of
active and intensified TB case finding. In addition, a MGIT BACTEC 960 system will be
procured to support scale up of culture and FLD of all MTB positive patients and monthly
culture testing for MDR-TB treatment follow-up as well as in-country 2nd line DST.
Childhood TB-specific guidelines and training curriculum will be developed and health
workers trained on paediatric TB case detection and management, followed by post
Swaziland TB and HIV Concept Note
04Nov 2014│ 56
training supportive supervision and mentorship.
Case detection and diagnosis - Above-allocated funding request
Funding will be requested to support an additional 9 Microscopists to support the upgrade
of mini-labs to peripheral laboratories with GeneXpert MTB/RIF diagnostic testing and
smear microscopy for treatment monitoring facilities. No infrastructural renovations are
required for the upgrades of these mini-labs as the upgrades are based on the availability
of rapid molecular diagnostic tools for TB and HIV. A total of 9 iLED Microscopes will be
procured and installed in the upgraded mini-labs to be used for TB treatment monitoring
and diagnosis of parasitic diseases. An additional 9 GeneXpert MTB/Rif machines will be
procured to enhance access to rapid molecular TB diagnosis as GeneXpert MTB/RIF was
adopted in 2011 as the initial diagnostic test for all presumptive TB cases, regardless of
HIV status or history of previous treatment/employment. This compliments the already
installed 38 machines and will be deployed in underserved populations with limited
coverage of the NSTS. Cartridges will be procured for new GeneXpert MTB/RIF units
including extended warranty packages and calibration kits.
In addition, funding will be requested to procure 115,200 GeneXpert cartridges in
2016/2017 as well as to support laboratory strengthening activities to improve laboratory
infrastructure, infection control practice and quality control measures in 11 peripheral
laboratories to increase access to quality-assured basic TB diagnostic services. To improve
laboratory performance and quality, funding will be requested to supplement the
Swaziland Health Laboratory Services (SHLS) budget to facilitate the development of the
TB Laboratory specific strategic plan, bacteriology guidelines, Standard Operating
Procedures (SOPs) and External Quality Assurance (EQA) guidelines will be updated.
Refresher trainings for laboratory personnel and supervisors on microscopy and EQA, will
be maintained.
Treatment – Within allocated funding
While all facilities in the country provide TB screening and treatment continuation
services, the facilities accredited to initiate TB treatment (Basic Management Units
(BMUs)) will be increased nationally from 86 to 145 sites by 2019 with prioritization of
sites providing HIV care to promote the one-stop shop model. Decentralization of BMUs
to lower level facilities within the communities is an ongoing activity supported by the
Swazi government through a World Bank loan for HR, infrastructural refurbishment and
Infection Prevention and Control (IPC) implementation.
The NFM funding will support the retention of the existing 24 Adherence Officers and
recruitment of an additional 10 to facilitate favourable treatment outcomes in patients.
Rural Health Motivators (RHMs) are community-based and will also be engaged to
provide treatment support for patients on drug susceptible TB treatment and ART
adherence support, contact tracing and TB/HIV screening and testing. Each of the 5000
RHMs will be assigned a DS-TB patient although as the case detection increases, RHMs
will be assigned more than one patient. Adherence officers are based at facilities and liaise
with DR-TB Community Treatment supporters, Rural Health Motivators (RHMs) and
nursing staff to ensure timely defaulter tracing of patients, screening and testing of
household contacts, transportation of samples to peripheral laboratories and feedback of
lab results to the facilities. They play a critical role in treatment adherence monitoring of
drug susceptible patients as well as supervision of community health care workers.
Adherence officers provide the link between community-facility structures and facilityregional structures as they report on community initiatives to the Regional TB/HIV
Coordinators. They are attached to 34 high volume hospitals and health centres who have
mother-baby relationships with smaller surrounding clinics. Ten motorbikes were
procured under the current R10 TB grant and funding will be requested to procure an
additional 24 motorbikes to support the functions of the Adherence Officers as they will
also play a vital role in adherence support of TB/HIV co-infected patients.
Swaziland TB and HIV Concept Note
04Nov 2014│ 57
The government of Swaziland has committed to ensuring that all diagnosed TB patients
(both private and public settings) receive free TB therapy (First and Second-line drugs)
and support including inpatient management and adverse event management.
Program Management – Within allocation funding request
Enhancement of the coordination functions of the National TB Control Programme at
national and regional levels is key to successful implementation of the country’s NSP
2015-2019 for TB care and control. This informed the recognition of the programme
management module as a critical component of the Swaziland Concept Note.
Policy, planning, coordination and management
Maintain positions of key NCTP staff.
The funding will be used to retain key NTCP staff not yet absorbed into the government
establishment, critical laboratory staff at NTRL and key community health workers funded
under the existing TB R10 grant, recruitment of additional NTCP staff at national level to
supervise and monitor community and research activities as well as MDR-TB medical
officers and nurses at regional level. There is a strong need for PMDT coordination to be
strengthened at both national and regional level.
Technical Coordination meetings.
This is considered crucial to strengthen coordination across the three levels of the TB
programme to ensure consistency in application of the national guidelines as well as
continuous appraisal of programme performance. Funding is requested to support annual
program review and workplan development meetings to respond to the current gaps in
ensuring regularity of technical coordination meetings due to funding constraints.
Conduct quarterly DR-TB coordination meetings at regional level.
To strengthen ongoing decentralization of DR TB services, quarterly DR TB coordination
meetings at national level will be crucial. The meetings will provide a forum to focus
specifically on DR TB clinical and programmatic issues with the view to ensure continuous
capacity building at the regional level.
Maintain functional transport for programme activities.
Funding is requested to support the procurement of 24 additional motorbikes to be used
by the Adherence officers in conducting defaulter and contact tracing activities as well as
close supportive supervision of the community-based active case finding initiative. These
will complement the 10 motorbikes procured under TB grant R10. The maintenance,
service, insurance and fuel will be covered by the government through the ministry of
Health Transport Department.
Program Management Module - Above Allocated funding Interventions
Strengthen programme logistics support.
With the proposed aggressive community-based active case finding initiatives moving
from national to community programmatic management, intensive supervision is required
particularly of M&E activities. The funding will be used to procure 5 new vehicles to
replace old vehicles procured under TB R8 grant. These vehicles will be used to facilitate
support supervision of the Prevalence and Drug Resistance Survey, Monitoring and
Evaluation at community and facility level as well as community DOTS supervision. The
maintenance and running costs of these vehicles will be supported by the government.
To support evidenced-based policy making and a learning health system, ongoing capacity
strengthening is critical. Funding assistance will be requested from Global fund to
continue ongoing support of PMDT and M&E training as well as attendance at
Swaziland TB and HIV Concept Note
04Nov 2014│ 58
international/regional meetings, which facilitate sharing of best practices in TB Control
between TB programs and Technical experts. Funding to conduct annual Implementation
Research training workshops will also be requested.
TB Specific Monitoring and Evaluation Module - Within Allocated funding
Adequate support to the M&E interventions will ensure that TB patients are timely
registered, notified, tracked and monitored which will result in improved programme
management. Given the importance of demonstrating outcomes and impact, special
attention has been given to the M&E module in this proposal. Routine data quality
assessments have shown a considerable gap in the TB recording and reporting of cases.
The NTCP will conduct the following programmatic data review meetings:
i.
ii.
iii.
iv.
Regular regional and national quarterly review meetings at all levels to monitor
performance.
TB Laboratory quality review meetings
More emphasis will also be put on routine and external data quality assessments
which will enable the programme to identify and address data quality issues. To
ensure this, joint TB/HIV support supervision and mentoring will be conducted by
the National Data Quality Improvement teams consisting of the DOTS
coordinator, TB/HIV Coordinator, Laboratory focal person, M&E officers,
Paediatric Coordinator, TB IPC Coordinator and Clinician Scientist.
Joint TB/HIV External Programme Reviews.
The allocated funding is proposed to strengthen supervision and mentoring at all levels in
terms of frequency and quality to improve TB care and programme management through
implementation of regular supportive supervision visits and training. Collaboration with
the HIV programme in quality data review of TB/HIV indicators has been ongoing and
this integration will be maintained.
Monitoring and Evaluation - Above Allocated funding
The introduction of an electronic TB register (eTR) will improve patient record
management and facilitate timely monitoring, reporting and recording of treatment
outcomes as the HMIS is unable to accommodate all required TB data variables. The core
reason for the eTR development is to simplify TB patient follow up and thus improve the
sputum conversion and treatment success rates. This TB register stores a line list of all the
TB patients and their treatment supporters. This will enable clinicians and NTCP staff to
know which TB patients;







Have missed their scheduled review dates
Are expected to come to the TB clinic for a follow up sputum examination or for other
services like HIV Counselling and Testing, Cotrimoxazole prophylaxis etc,
Have not been linked to a treatment supporter or which treatment supporters in the
community have no TB patients to follow up.
Are HIV positive and then refer them to the appropriate HIV/AIDS service providers or
ART clinics
Instantly generate quality and timely reports to the NTCP, MoH and to partners.
Most importantly, although data will be entered for all TB patients diagnosed from
different health facilities, eTR will make it possible to get the performance for each health
facility.
Additionally, eTR will generate quarterly reports to the NTCP per health facility or per
health sub district
Furthermore, eTR will enable regular review of past program performance to enable the
NTCP to set realistic targets when writing project proposals i.e., to analyse a set of about
18 TB-HIV related indicators, group the analysis results by week, month, by quarter or by
Swaziland TB and HIV Concept Note
04Nov 2014│ 59
year for whatever time period chosen. To ensure successful roll-out of the electronic TB
register, the funding request will support procurement of computers and relevant
software, and training of all (community and facility) health workers on TB recording and
reporting. This is intended to strengthen data quality across health facilities, regional and
national levels.
The above indicative funding allocation is also proposed to fund procurement of
computers for administration to replace those procured under the R8 TB grant.
Surveillance and Research – Allocated funding
As a follow up to the DRS conducted in collaboration with MSF in 2009, the NTCP
through the support of Global fund will conduct a repeat DRS as the country is currently
faced with increasing levels of drug-resistant TB among new cases. Swaziland has
prioritized the TB prevalence survey as the country currently relies on WHO modelled
estimates, which show an increasing incidence rate whereas TB case notification in the
country is on a downward trend.
Surveillance and Research – Above Allocated funding
Funding assistance will be requested from GF to conduct a paediatric and adult TB
inventory study to facilitate an accurate understanding of the level of under-reporting of
TB cases nationally. This is critical for TB Control activities especially as the country has
been experiencing a declining case notification against the WHO estimated notifications.
Currently, childhood TB cases comprise 10% of the adult cases which is much below the
WHO recommendation of 15%. Therefore, the inventory study to ascertain whether cases
are being missed and where they are being missed in order to develop context-relevant
interventions to improve childhood TB case detection.
TB-HIV Module
With an 80% TB/HIV co-infection rate, strengthening the implementation of collaborative
TB/HIV activities remain a high priority in the TB NSP 2015-2019. This NFM funding
request responds to the programmatic gaps identified by the NTCP, SNAP and
stakeholders to strengthen the Integrated “one-stop shop” model of integrated TB/HIV
care and facilitate expansion in terms of coverage. This is aimed at reducing opportunity
cost for patients as follow up appointment are synchronized.
The government of Swaziland in collaboration with developmental partners has made
significant progress in reducing the burden of HIV in TB patients through the financial
commitment towards increasing uptake of HIV testing and counselling (HTC) among TB
patients, cotrimoxazole preventive therapy (CPT) uptake amongst HIV positive patients
and the provision of free ART for TB/HIV co-infected patients. More specifically, PEPFAR
is currently contributing $2M for TB, TB/HIV and MDR-TB activities per year and $2M
for HSS especially laboratory strengthening and NSTS. Starting April 2015, PEPFAR has
committed through new funding mechanism: TB/HIV-$3.2 M per year and $2.1M lab HSS
per year.
It is vital to note that TB/HIV activities are embedded within the joint implementation of
the TB and HIV Programmes. Therefore, activities listed under this module are not the
only activities prioritized by the Programmes to address TB/HIV collaboration. In
addition to these coordination activities for which funding is requested are collaborative
activities already fully funded under the governments TB/HIV budget to address TB/HIV
activities. Specifically, actions to reduce the burden of TB in PLHIV (3Is) are further
detailed below:


IPT coverage for both children and adults – all first line anti-TB drugs are
procured by the Ministry of Health in its budgetary commitment to TB Control.
Government has also secured a World Bank loan aimed at infrastructure
refurbishments of health facilities to address TB Infection Prevention and Control
(IPC) challenges.
Swaziland TB and HIV Concept Note
04Nov 2014│ 60

Intensified Case Finding in HIV clinical settings including MNCH – additional
Cough Officers have been requested under the TB Care and Prevention module to
strengthen and expand TB case finding among PLHIV, pregnant women, children
under 5 years
Table 7 Anticipated cumulative coverage/impact with GF investment (TB-HIV)
Coverage indicator
% TB patients who had
an HIV test result
recorded in the TB
register
Investment
Baseline
Expected coverage/impact
2013
2015
2016
2017
96%
96%
97%
98%
90%
71%
67%
6%
26%
31%
96%
97%
98%
Domestic
and
other
sources
including
HIV
grant
No baseline
Allocated
+
Domestic
and
other sources
No baseline
Above allocated
+ Allocated +
Domestic
and
other sources
No Baseline
Assumptions: HIV testing for TB patients remains high priority in the new strategy. In 2013
96% 0f TB patients were provided with an HIV test and informed of their results
Coverage indicator
Percentage of HIV
registered TB patients
given
antiretroviral
therapy during TB
treatment
Investment
Baseline
Expected coverage/impact
2013
2015
2016
2017
75%
83%
88%
90%
Domestic and
other sources,
including HIV
grant
No baseline
64%
48%
42%
Allocated
No baseline
30%
31%
29%
Above allocated
Assumptions:
ART uptake for co-infected patients has been increasing and the program targets to intensify the
rate of enrolment to 83% in year 1 of the strategy rising to 90% by the final year of
implementation. This is directly aligned to the targets set in the new NSP
TB-HIV (Allocated funding request)
Activities aimed at reducing the burden of HIV among TB patients includes the provision
of HIV testing and counselling, ART, CPT and IPT for all adult contacts. The
implementation of these activities is monitored by SNAP and is further discussed under
the HIV sections. The NTCP implements activities aimed at reducing the burden of TB
among PLHIV and this includes the provision of IPT for paediatric contacts under 5 years
of age, strengthening Intensified TB Case finding (ICF) in all entry points among PLHIV
as well as MNCH clients and to ensure the prompt linkage of these patients to quality TB
treatment and care, as well as strengthening TB Infection prevention and Control (IPC)
Swaziland TB and HIV Concept Note
04Nov 2014│ 61
measures in health care facilities and congregate settings to prevent nosocomial TB
transmission. Through the Swazi government and World Bank, the coverage of the
integrated TB/HIV service delivery model is currently being expanded to ensure that coinfected patients receive both services under one roof.
With effect from April 2015, HIV/TB funding from PEPFAR will be consolidated as a
single funding stream for HIV/TB for each region and the ongoing funding commitment
includes support of national and regional TB/HIV data review meetings in the form of the
National HIV/TB Semi-Annual Review (NHSAR) meetings and the Regional HIV/TB
Semi-Annual Review (RESAR) meetings. The PEPFAR funding will close the funding gap
in ensuring regular and consistent joint TB/HIV programming and planning meetings,
which is critical to strengthening the TB/HIV collaboration between the programmes and
partners. This includes strengthening of the existing National TB/HIV Coordinating
Committee (NCC) and decentralization to regional level.
The NFM funding requested will complement the TB IPC infrastructure refurbishment
project with the provision of prefabs, sputum booths, Hepa filters and UVGI lights to 45
non-IPC compliant facilities not earmarked for major infrastructural repairs. These
facilities provide integrated TB/HIV services. This activity also includes annual
Coordination meetings with the Ministry of Housing and Urban Development to ensure
new housing construction meets minimum ventilation standards. In settings like the
mines and uniformed service establishments, infection control will be enhanced through
targeted training of health workers in their institutions. On the other hand, in informal
mining settings (especially among the migrant miners based in neighbouring countries),
infection control will be re-enforced through training of selected CSOs, who will in turn
cascade trainings to peer educators for infection control sensitization in informal
congregate settings.
This funding will also support strengthening the implementation of Personal Protective
Equipment (PPE) in health care facilities including the procurement of N95 respirators
and Fit test kits for health care workers.
TB/HIV (Above allocation interventions)
Ensure proper management of comorbidities in health care facilities
This intervention aims at strengthening prevention, screening, diagnosis and management
of comorbidities, especially diabetes in health care settings through collaboration with
other national health programs involved in the management of comorbidities, i.e. NCD
program, Nutrition Council program. It will also entail integration of TB services in the
management of non-communicable diseases. Funding will thus be requested to:
1. Procure equipment for diagnosis of co-morbidities (BP machine and Glucometer
for diabetes and hypertension) for BMU's (NTCP) and HIV Care Settings (SNAP).
2. Conduct stakeholder workshop (NCD programme, NTCP & SNAP) on the TB NCD
integration programme.
3. Conduct training workshops for health care workers on the management of comorbidities (TB/HIV/Diabetes) and Opportunistic Infections
Decentralize TB initiation and follow up to lower level clinics including
PHUs
All PLHIV confirmed with TB will immediately be initiated on anti-TB treatment, under
clinical supervision. This intervention will ensure that lower level clinics and PHUs are
accredited to initiate TB treatment so that all confirmed TB cases from these health care
facilities are promptly initiated on treatment by qualified health care workers trained on
TB/HIV management. It will also facilitate training of students in nursing and
environmental health as well as clinicians on appropriate management of TB/HIV coinfection, an important aspect of Continuing Medical Education (CME). The requested
NFM funding will support the following activities: Strengthening referrals systems of nonSwaziland TB and HIV Concept Note
04Nov 2014│ 62
integrated facilities and diagnosis at the PHUs to facilitate provision of comprehensive
TB/HIV services, Conduct pre-service training attachment for HCW on TB/HIV
management and Conduct joint supportive supervision and mentoring to HCW working in
TB/HIV management settings
MDR-TB Module
The emerging threat from drug resistant forms of TB continues to undermine gains in TB
control efforts. With the ongoing rollout of GeneXpert MTB/Rif, there has been a
sustained increase in case detection of resistant forms of TB, however, case finding
remains constrained by coverage in diagnostics. This is compounded by the lingering
treatment access gap where not all patients diagnosed are put on treatment. The funding
request will optimize case detection and close the diagnostic-treatment gap through
expansion and decentralization of MDR-TB facilities to support community-based MDRTB care and support.
Activities supported by the government are ongoing to improve Infection Prevention and
Control (IPC) in the health facilities and community through the implementation of the
three levels of IPC measures namely, Administrative, Environmental and Personal
protection. It aims to strengthen the Finding cases Actively, Separating safely and Treating
immediately as appropriate strategy (FAST). The anticipated coverage/impact is
summarized below;
Table 8 Anticipated cumulative coverage/impact with GF investment (MDR TB)
Coverage indicator
Number
bacteriologically
confirmed,
resistant
TB
and/or
MDR
notified
Investment
Baseline
Expected coverage/impact
2013
2015
2016
2017
403
708
905
1,038
Allocated
No baseline
566
724
830
Above allocated
No baseline
142
181
208
Above allocated
+ Allocated +
Domestic
and
other sources
No baseline
708
905
1,038
of
drug
(RR
TB)
Assumptions: WHO estimates used to estimate country need and set country targets, to be
revised with results from proposed DRS
MDR TB Module (Allocated funding interventions)
Key affected populations
Intensified TB case finding among high-risk populations (children, miners and migrant
workers, prisoners (there are no policy guidelines specific for prisoners as they are treated
the same as the general population), PLHIV, and health care workers), will be pursued.
The Swaziland Ministry of Health through the TB Program has successfully mobilized
resources from World Bank and Global Fund to support the implementation of
interventions targeting mineworkers. A national consensus meeting and partnership
forum has been convened to mobilize for a multi-sectoral engagement in addressing the
vulnerabilities of miners. Small scale advocacy and social mobilization activities have been
conducted to sensitize miners, ex-miners and their families on their risk to TB acquisition
and services available to increase access and uptake of TB services by this population
group. A local multi-sectoral program implementation committee has been appointed to
Swaziland TB and HIV Concept Note
04Nov 2014│ 63
fast track implementation of the regional harmonization framework.
The TB NFM will support the existing TB ACSM unit to conduct media and community
awareness campaigns and social mobilization activities to empower the general population
and sensitize communities on DR-TB early recognition, diagnostic and treatment support
services as well as IPC best practices.
Case detection and diagnosis
This funding request aims to strengthen the diagnosis of drug resistant tuberculosis
through GeneXpert MTB/RIF, liquid culture and DST (First- and Second-line) as per the
national diagnostic algorithm. Details of interventions proposed to be funded are as
follows;
Currently culture and DST services are offered by one national TB reference laboratory in
Mbabane (NTRL), which is heavily supported by Global Fund and the EXPAND-TB
project ending in Dec 2015. Although there is good access to culture and first-line DST,
access to second line DST is very limited, this is due mainly to a shortage of laboratory
scientists trained to conduct 2nd line DST. The NFM funding request will support the
procurement of reagents for liquid culture, both phenotypic 1 st and 2nd line DST and a
MGIT BACTEC 960 system. Service contracts for essential equipment will be secured.
DR-TB treatment.
Decentralization of the management of drug-resistant TB to the regional and community
level will be supported while strengthening the capacity of the existing MDR-TB Regional
clinical teams (each team has 2 MDR-TB Doctors and 3 nurses) to provide continuous
support supervision and mentoring to decentralized regional facilities. The Regional teams
also provide community outreach services and conduct home assessments for DR-TB
patients. Each MDR-TB patient is assigned to a Community Treatment Supporter for the
duration of therapy to facilitate treatment adherence, care and support as well as early
recognition of adverse events. Funding will be requested to support the existing250 Global
Fund-supported Community Treatment Supporters (CTS) who provide treatment
adherence and support, household TB screening and contact-tracing services. An
additional 250 CTS will be recruited to augment this Community DR-TB Care (CTBC)
service integrated with HIV testing and ART adherence support (for the duration of TB
treatment) as well as condom distribution. This request will support the retention of the
Regional MDR-TB clinical teams and Community Treatment Supporters and capacity
building of health care workers through training on PMDT to ensure provision of quality
care at regional and community levels.
The management of adverse effects of second line anti-TB treatment will be strengthened
and institutionalized as an integral component of DR-TB case management. Audiology
assessments will be provided to all patients on 2nd line anti-TB treatment. The funding will
be used to purchase audiology equipment and train health care workers on audio
screening to facilitate the scale up of audiology services to all DR-TB treatment initiating
sites. Hearing aids for patients in need will be procured.
The contribution towards GLC technical support will be paid at the rate of US$50,000.00
per annum from the allocated funding.
Above allocation Interventions
Case detection and diagnosis of DR-TB
The country plans to increase access to and quality of culture and DST. All patients
identified as MTB positive through GeneXpert will undergo 1stline DST and those with Rif
Resistance will undergo 1stand 2nd line DST. Therefore funding is requested for training of
staff of the NTRL to perform 2nd line DST at a supra-national reference laboratory
accredited with the global WHO SNRL network. The post training mentorship and
Swaziland TB and HIV Concept Note
04Nov 2014│ 64
technical support by the SNRL will also be supported. The Laboratory Information System
(LIS), which is currently installed at NTRL, will be rolled out to all peripheral laboratories
to ensure results are made available swiftly to the clinician who had refereed the specimen
for optimal case management.
Key affected populations
The NFM funding will support the conduct of engagement and sensitization meetings with
management in the high-risk populations and congregate settings on DR-TB IPC e.g.
Mining organisations, Wellness Centre, uniformed forces and industry management etc.
DR-TB Treatment
The above-allocated funding request will be used to further strengthen capacity for
community DR-TB management, care and support.
A surveillance system for GIS mapping of DR-TB patient coordinates has been developed
to facilitate patient follow up and monitoring. Funding will further strengthen this
surveillance system, procure additional GIS mapping devices
The Global Fund has been supporting the procurement of 50% of the country’s need for
second line anti-TB medicines. The NFM funding will support this activity for the
treatment of 50% of the estimated 3103 DR-TB patients throughout the 3-year
implementation period. Swazi government will secure the remaining need of 2nd line
drugs and will continue to do so after the grant ends.
To ensure continuation of treatment, nutritional support and transport allowances to
attend clinical reviews will be provided to DR-TB patients as part of psycho-social support.
This is a continuation of support under the currently existing R10 TB grant.
The NFM funding will support the programme to focus on the improvement of the quality
of life among DR-TB patients and to facilitate the Palliative care coordinators
(representatives from SNAP and NTCP) to develop guidelines on Providing Palliative Care
to Patients with DR-TB, these will be in line with the ‘Declaration on Palliative Care and
MDR/XDR-TB’. All health care workers managing MDR-TB patients will be trained on
palliative care.
3.2.3. Health Systems Strengthening
In an effort to address the key gaps in high-priority areas for health system strengthening,
Swaziland has developed a prioritized request for the Global Fund for the four strategic
pillars: i) health information systems and M&E, ii) procurement and supply chain
management, iii) service delivery and health and iv) community workforce described in
more detail in Sections 1 and 3.1. Please see table 1 below for the total health systems
strengthening funding request.
i) Health Information Systems and M&E
The funding request for HMIS is 3.8M USD over the three-year period to address the
resource gaps for the “real-time” model of the CMIS as described in Section 3.1. Please see
below for further details on the funding request (Table 9).
Table 9: Funding Request Details for HMIS
LAN
WAN
Original
“hybrid” model
Local Area Network
(LAN) connection to
facility
Two network
connections per site
Swaziland TB and HIV Concept Note
Evolved
“real-time” model
Same
Networking to ALL clinical
service points per site
Gap Being Requested
from Global Fund
LAN connections to an
additional 91 health
facilities (138 sites total)
Installation of networking
to additional service points
at 128 additional facilities
04Nov 2014│ 65
Hardware/
Peripherals
- 2 computers per site
- 1 printer per site
- 2 UPSs
- Computers at all clinical
service points
- One UPS per computer
- Additional printers to
support patient file (3 per
site)
Purchase of:
- 20 PCs per site
- 20 UPSs (one per PC)
- 3 printers per site
The additional items requested in order to support full implementation to these sites are:
- Transport 138 facilities x 24 trips per facility
- STTA (I Technical Advisor– Software Development)
- STTA (I Technical Advisor– Network/Hardware Engineer)
- STTA (I Technical Advisor– Data Management)
- Procure consultancy services on development and operationalization of Unique
Patient Identifier & registry system.
ii) Procurement and Supply Chain Management:
In order to address the key supply chain and procurement gaps described in Section 3.1,
Swaziland is requesting for a total of 2.54M USD over the course of 3 years. Please see
below for further details on the request.
Capacity Building Activities: MOH requires a procurement consultant to improve in house
capacity of procurement department and to adopt international best practices. Trainings
are required at facility level on requisitioning and good storage practices to avert wrong
requisitions, over and under-stocking and unwanted expiries and to ensure quality of
medicine until it is provided to patients/clients.
LMIS implementation: Currently, MOH is utilizing two different systems at CMS and
National Lab Warehouse. CTS is successfully implemented at National Lab Warehouse but
CMS is still utilizing Access Based software, which does not provide the strong reports to
analyse the logistics data. Secondly, MOH is planning to have a web based integrated
LMIS to collate data at one site for planning purpose. The requirements are as follows;
1. Installation of Computers at Central and Regional Level
2. Training on Web based LMIS for CMS and regional staff
3. Annual Maintenance of LMIS system.
Reagents for the Quality Assurance Laboratory: The country has no functional Quality
Assurance Laboratory and to operationalize the QC laboratory based at CMS, the Ministry
of Health has through GF and Taiwanese government procured machinery for the QC
laboratory. The request is for GF to fund reagents for three years, thereafter government
will be in a position to continue with the procurement of reagents.
Warehouse Improvements: Shelving of the ART warehouse — The rented ART Warehouse
currently stores HIV/ART products, Malaria Nets, and Pharmaceuticals bulk products.
Pursuant to the Warehousing Assessment Report it was recommended that with shelving
space efficiency gains would be made and Laboratory bulk commodities can also be stored
in the ART warehouse to provide relief to the Lab’s limited space. This is the first step
towards integration of the usage of warehouse space.
From this year onward government is releasing the procurement budget for all drugs on a
two-quarter advancement to avoid stock outs. This means the ART warehouse will carry
more stock and the shelving to mitigate the space needs.
4. Refurbishment and Operationalization of Integrated Warehouse
Government is planning to procure an existing warehouse to resolve storage and rental
issues. In this regard, government seeks the partners to refurbish and operationalize the
warehouse by providing the following support:
-
Refurbishment of warehouse
Shelving of warehouse
Swaziland TB and HIV Concept Note
04Nov 2014│ 66
-
Purchase of operational equipment i.e. fork lifters, trolleys, pallet jack, pallets
Purchase of furniture and air conditioners
5. Distribution
Vehicle Purchase: Toyota Land-cruiser panel vans — The current CMS boxed vans are no
longer in a working condition. The Central Medical Stores is using 4 ton boxed trucks and
the challenge with using the current trucks for all terrains is that they don’t reach all the
facilities. During the summer months (rainy season) these trucks deliver mainly to
facilities that have paved roads only. Additionally, the current distribution system cannot
respond to emergency situations, facilities have to collect for themselves from CMS and
the lab and those in remote areas are unable to get supplies timely. The request for 4
Toyota Land-cruiser panel vans will be used to deliver supplies to all facilities even those
that are in remote areas. The ministry has reviewed the process flow in CMS and identified
weaknesses in inventory recording and issuing, therefore implementation of bar code
scanners will improve accuracy of inventory including those for HIV and TB. The specific
request is for computers, purchase of bar code scanners and printers, training, and
software for service delivery.
In order to address the high-priority service delivery gaps described in Section 3.1,
Swaziland is requesting for a total of 1.4M USD within allocation and 0.9M USD above
allocation over the course of 3 years.
The MOH seeks to ensure that every client that comes into the health system is provided
with full comprehensive care and treatment services regardless of disease. The MOH
developed an Essential Health Care Package (EHCP) to address the disease burden in the
country including HIV/AIDS and TB. An assessment of infrastructure and equipment to
implement the EHCP was done and gaps identified in order to fully implement.
The GF request will support renovations or refurbishment for Infection Prevention
Control purposes and EHCP implementation. Activities will include an Infection Control
Assessment of the 18 high volume facilities and then putting either more windows or
correct windows in the health facilities or installing mechanical ventilation in some cases.
In some instances, extension of the facility may be necessary. The second aspect is to
ensure that the facilities are equipped to provide integrated services to people with HIV or
TB. This will include procuring all necessary equipment for the identified facilities for
them to be able to deliver integrated services.
The equipment for the facilities will include but not limited to point of Point-of-Care
chemistry, viral load machines, pulse oximeters, Sphygmomanometers (Electronic or
Automatic), Spirometers, Doppler vascular bidirectional, Sterilizing Units, Steam,
Tabletop, BP machines, glucometers, vinometer’s and others. The request also includes
capacity building for the staff at these facilities in order to capacitate them to use the
purchased equipment as well as to provide the new services. 90 health care workers across
the 18 facilities (Primary health care facilities have an average of between 4-5 nurses x 18)
are targeted for training. The target is to cover 18 high volume facilities over 3 years in
order to have the highest impact.
iii)
Healthcare Workforce:
The national Health Sector Strategic Plan identifies shortage of healthcare providers and
managers as a key challenge for healthcare systems strengthening. To support this effort,
Swaziland is requesting for a total of 0.28M USD over the course of 3 years within the
allocated amount, and 0.35M above the allocated amount. The following activities will be
undertaken.
-
Training: funding to provide the training and development namely: basic
education (pre-service training), postgraduate education (specialization) and
professional development (in-service training and continuing medical education):
a. Training of nurses on advance nursing programs (e.g. midwifery)
Swaziland TB and HIV Concept Note
04Nov 2014│ 67
b. Train health admin on health systems management (9 months diploma in
Botswana)
-
Orientation: In an effort to address a gap around HRH development, Swaziland is
seeking funding to provide the following orientations and trainings
c. Conduct orientation for newly appointed and promoted health officials
d. Implement the renewed primary healthcare strategy for Africa
e. Orient critical ministries on the social determinants of health with emphasis
on HIV/AIDS, TB, Malaria and NCDs (5 key ministries)
Table 10 Funding request for priority Health Systems Strengthening (HSS)
Allocations
% Funding
2015
2016
2017
TOTAL
1,232,561
1,029,846
280,654
2,543,061
1,085,863.00
1,456,708
1,290,189
3,832,761
Health and Community
Workforce
109,424
72,635
105,586
287,645
3.6%
Service Delivery
466,595
479,475
479,475
1,425,544
17.6%
2,894,443
3,038,664
2,155,904
8,089,011
Procurement and Supply
Chain Management
Health Information
Systems and M&E
31.4%
47.4%
Total Funding Request
100%
HSS Above allocation request
Health and Community
workforce
Service delivery
TOTAL
Swaziland TB and HIV Concept Note
198,524
74,340
74,340
347,204
299,001
299,001
299,001
897,003
497,525
373,341
373,341
1,244,207
n/a
n/a
n/a
04Nov 2014│ 68
3.2.4. Community Systems Strengthening
The CSS is an integral part of service delivery and scaling up TB/HIV/Malaria and other
social services. Swaziland’s epidemic has matured with systems in place to support an
effective and decentralized response. The adoption of the WHO guidelines provides both a
challenge and opportunity for scaling up services at community level and improved
targeting of key affected populations. Good models continue to be implemented in small
geographic areas without being replicated due to structural, resource and capacity
constraints. The targeted interventions therefore seek to ensure measureable and effective
response by civil society, communities and key populations in contributing to meeting the
objectives of the national strategies.
The prioritized interventions have taken into account the TB and HIV strategies and
combined responses for more effective programming and are based on the six building
blocks of CSS. Implementing the interventions will impact the promotion of developed,
informed, capable and coordinated communities and community-based organisations,
groups and structures.
The funding request for strengthening community systems is based on the three strategic
areas:



community based monitoring for accountability,
social mobilization and
institutional capacity building.
The foregoing strategies are meant to contribute to the overall goal, which is to improve
community systems and structures leading to and coordinating community based service
delivery for TB, HIV and Malaria services. The activities listed under the three pillars form
part of the request for funding from GFATM.
Community based monitoring for accountability: The activities include baseline
assessment to understand who is doing what and the community gaps and needs,
developing a service directory. The subsequent product is a clear data base of where to
refer people in need of various community interventions. Community reviews, monitoring,
documentation and reporting provide a platform to interrogate accountability. Other
activities will include harmonizing tools and establishing linkages in data management.
Key among these activities are rights-based programming, gender equity and equality,
including developing indicators to track progress, and disseminate data for monitoring. To
facilitate this standardized community service delivery curriculum will be developed and
RHM will be trained. Similarly, training for CBOs will be organized to improve skills,
recording and reporting. In addition, community health workers will be trained using the
standardized training curriculum to provide integrated services.
Empowered communities translate to more equitable services, less stigma and
discrimination and greater involvement and ownership of country processes. This will
support the prevention module on the key population section ensure increased access to
services and also reduce barriers to access, stigma and discrimination, thus creating an
enabling environment. To a greater extent people living with disability will henceforth
have more access to HTC, FP and other health services, as their disposition structurally
Swaziland TB and HIV Concept Note
04Nov 2014│ 69
disadvantages them from easy access to services. The government will continue to provide
support for this group to ensure access to HIV/TB and health information, education and
communication material.
The funding request is to support the implementation of the above activities that are
critical for ensuring community-based monitoring and establish a functional service
delivery mechanism at the community-level. The community leaders and their committees
will play a role in monitoring health services thus strengthening their roles as important
gatekeepers. Their role includes but is not limited to ensuring the selection of volunteers
and providing facility level oversight as part of the health committee that determine tariffs
and other policy decisions. Influencing their decision making ability impacts the quality of
health services
Social mobilization, building community linkages, collaboration and coordination: The
activities include developing a CSS framework, to develop/adapt a service package and
ToRs and accredit community volunteer health workers based on the standardized
curriculum, to review them, develop coordination and communication guidelines, also
develop a volunteer policy and conduct regular coordination and review meetings.
Furthermore, mechanism for scaling ongoing economic strengthening activities for
vulnerable women and girls will be implemented (small business, saving, credit).
Scorecards to monitor quality of services, drug reactions, and drug stock outs including
understanding the patient charter will be used as a process to build a responsive
community that is well collaborated and coordinated. Advocacy dialogues at the
community level on access to services for all population groups will be conducted.
The government has established the Ministry of Tinkhundla Administration and
Development with mandates for creating an enabling environment, community
mobilization and supporting community level services. The government has employed 12
community development officers who are responsible for mobilization and coordination of
services. Nevertheless, the numbers are limited to few communities and there is a need to
scale up and expand to more communities.
The GF will support the above activities including improvement of the skills of existing
officers and support communities to expand the reach of the program while contributing
to the promotion of gender equity. All these will be within allocation.
Institutional capacity building activities include training of community based
organisations on project development and management; organizational development, and
finance and grant management. MOH developed community referral tools, SOPs, and
curriculum, thus harmonizing and rolling these out will ensure standardized
implementation and improve the quality of community services. Well-defined referral
mechanisms will ensure collaboration with health facilities. Currently, PSI supports
Interpersonal Communication Agents who are tasked with institutional support including
public education for HIV services demand creation. However, as these are donor-funded,
there is a need to establish an institutional capacity to absorb them in the long-term and
also to double their skills through training in other program areas and ensure their
integration to the larger community health and development programs.
The KaGogo centre clerk is also an integral part of the data system. Duties include
collection of reports and summarizing them before submitting to NERCHA. This grant will
pave the way for data quality through triangulation of data, operations research, case
studies including documentation of success stories to ensure evidence based and evidence
generating interventions, and this will be linked to the program coordination part of this
grant.
The funding from the GF will support institutional capacity enhancement as detailed
above. This will be achieved using the allocated amount.
Table 11 Funding request for priority CSS interventions
Swaziland TB and HIV Concept Note
04Nov 2014│ 70
Module
2015
2016
2017
Total
% Funding
Community based monitoring for
accountability
535,016.49
83,929.43
83,843.86
702,789.7
8
42%
152,155.10
341,158.24
254,157.05
747,470.3
9
45%
-
101,284.23
115,478.50
216,762.73
13%
687,171.59
526,371.90
453,479.41
1,667,022.9
0
100%
Social
mobilization,
building
community
linkages,
collaboration and coordination
Institutional capacity building
planning
and
leadership
development in the community
sector
TOTAL
1)
2)
3)
Swaziland TB and HIV Concept Note
04Nov 2014│ 71
3.3 Modular Template
Complete the modular template (Table 3). Note that the template allows access to
modules that are specifically relevant to TB and HIV components, in addition to modules
that are cross-cutting for both diseases.
To accompany the modular template, for both the allocation amount and the request above
this amount, explain:
a. The rationale for the selection and prioritization of modules and interventions for
TB and HIV, including those that are cross-cutting for both diseases.
b. The expected impact and outcomes of the interventions being proposed. Highlight
the additional gains expected from the funding requested above the allocation
amount.
HIV Program
Prevention for General Population
Rationale
In view of the fact that heterosexual transmission is the main mode of HIV spread, the
eNSF prioritizes prevention of sexual transmission and PMTCT as key to reduce HIV
transmission. Accordingly, interventions that are targeting populations at highest risk of
HIV infection including girls and women (aged 1-19 and 20-35), key populations and men
(aged 25-45) are prioritised in the concept note. Risky sexual behaviours such as low
condom use, intergenerational sex and early sexual debut are high among these groups. In
addition, factors such as low rates of male circumcision and gender based violence,
particularly sexual violence increase risk of HIV acquisition. All prevention activities
included in the concept note respond directly to the challenges highlighted in section one.
All prioritised interventions have a gap in funding and fall within priority areas in the
eNSF.
SBC: This request will support implementation of interventions aimed at increasing HIV
risk perception and uptake of HIV services, specifically the consistent and correct condom
use, MC, SRH, HTC and early uptake of ART among the targeted population. The
comprehensive prevention package (outlined in section 1.3) will be delivered through a
pool of already trained peer educators for in-school and community facilitators for the out
of school youth. Orientation on the prevention package structured sessions will ensure
facilitators and peer educators deliver the package systematically and in a harmonized
fashion. Already existing community structures such as the KaGogo Centres, community
development officers and NGOs will be leveraged on. A total of 100,000 young people in
schools are expected to be reached (33,400 per year) and 40,000 out of school young
people per year will be reached contributing to the target of reaching 50% of young people
by 2018 from 26% in 2011 (page 60 eNSF). The provision of mobile HIV/SRH services and
mobile technologies will complement the in-school and out of school interventions to
ensure young people have access and improved uptake of services.
Interactive radio drama programs will be used to complement and reinforce messages in
the comprehensive prevention package.
The anticipated outcome of this component will contribute to the increase in
comprehensive knowledge from 56% to 70% in 2018, an increase in HIV risk perception
and uptake of HIV/TB services.
Condoms: The the eNSF prioritized promotion and distribution of 10million condoms
annually, through the use of traditional (e.g. health facilities) and non-traditional (e.g.
salons, bars outreach, and other accessible channels). Currently AIDS Health Care
Foundation (AHF) has committed to procuring 4.4million condoms annually over the next
3 years. PEPFAR will also procure approximately 4 million specialty condoms and has
Swaziland TB and HIV Concept Note
04Nov 2014│ 72
allocated a budget of USD1.5 million for distribution and promotion of condoms for youth
and key populations. Due to cessation of UNFPA support for commodity procurement,
there will be a shortfall of 10 million condoms per year from 2015. However, this available
consignment fall short by 10 million Condoms which used to be supported by The request
to the Global Fund is for the procurement of 10million condoms to cover this shortfall.
At a coverage of 41.2 % (PSI Swaziland TMA Study, 2010), targeted and equitable
distribution and promotion also remains a gap. According to the 2012 UNFPA Rapid
Needs Assessment, young people indicated that they did not have access to condoms when
they needed them. Most condoms are currently placed in public toilets and in condo cans
which are often locked during the night making them inaccessible. Global Fund support is
requested to increase distribution through dispensing machines to be placed in strategic
areas to ensure availability of condoms 24 hours. Community health care workers from all
360 communities will be engaged to expand distribution of condoms at community level.
The government through the CMS will ensure community workers are trained on condom
reporting and promotion, whoever, the unavailability of portable storage for condoms has
hampered distribution efforts by community care workers. Currently community health
care workers are only able to carry a small number of condoms during door-to door visits.
As such the country is requesting support to purchase 600 condom storage bags to enable
community health care workers to carry and distribute condoms.
This will complement SBC initiatives which will promote consistent and correct condom
use among young people as a core area of focus.
The interventions for which funding is requested will increase distribution in communities
through non-traditional platforms and ensure 24 hour access in targeted areas,
contributing to increased condom coverage from 47% to 100% by 2018 and increasing
condom use from 80% in 2015 to 85% by 2018.
RMNCH linkages and gender-based violence (GBV): Swaziland is currently
strengthening national efforts to prevent and manage GBV. The MOH in collaboration
with the Ministry of Justice has established a multi sectoral national surveillance system,
one national guideline and a training manual for multi-sectoral response to GBV. A child
friendly court has also been established at the High Court in Mbabane and the government
has a plan to roll it out to the remaining 3 regions. This has been done concurrently with
the establishment of a One-Stop Centre in the Hhohho region through UNICEF and
PEPFAR for effective case management support and is in the process of establishing 3
additional centres in the remaining regions. The government has also upgraded the gender
unit to a department for purposes of ensuring prioritization of GBV within government
agenda. In spite of this, there remains significant underreporting of incidences of violence
and community awareness on GBV and its inter-linkages with HIV remains a gap and
there’s significant under reporting of incidences of gender based violence in the country.
Support is also requested for scaling up community outreach for prevention and awareness
of GBV and its available services. Through GF support community dialogues which will be
include community health days and the use of community champions for GBV. This will be
complemented by the provision of mobile HIV/SRH services outlined in the SBC section.
The unavailability of trained forensic nurses within health facilities has negatively affected
the management of cases, collection of evidence and ultimately the conviction of
perpetrators. This has impacted on underreporting of reporting of sexual violence cases
with less than 1 in 7 incidents resulting in females seeking help (VAC 2007). The GF is
therefore requested to support a six month training of 11 nurses on forensic nursing, who
will be deployed to all the secondary and tertiary health facilities in the country (11) and
linked to the on-stop centre in Mbabane. These nurses will facilitate improved
management of cases, better collection of evidence and increased conviction of GBV
perpetrators.
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It is anticipated that these interventions will improve community awareness and reporting
of GBV, strengthen referral and service uptake (PEP) and increase capacity of health care
workers, communities and duty bearers to respond to GBV.
Male Circumcision: The lessons learnt from the Accelerated Saturated Initiative which
was implemented under the 2009-20013 strategy for MC indicated a need to focus on
strengthening community mobilization and engagement of community gate-keepers to
drive and support demand creation and uptake of MC. Over the next five years PEPFAR
will be supporting provision of clinical services and localized demand creation through IPC
agents, targeted community mobilization and mobile clinical teams however, there
remains a gap in support for the engagement of key opinion leaders in creating a conducive
environment for uptake of services as well as supporting promotion of uptake of services.
The request to the GF is to support policy advocacy dialogues targeting gatekeepers such as
Chiefs, Parliamentary portfolio committees on HIV, church leaders, youth community
leaders as well as other community structures in advocating for MC service uptake.
The program statistics show that static sites show very low uptake of services whereas the
mobile outreach and campaigns have demonstrated much higher numbers for MC. By
September 2014, the number of men circumcised in static sites reached 2,423 whilst
mobile outreached yielded a number of 7,445 circumcisions, reaching 10,557 of the 12,000
2014 target. The outreach model is effective, however, experience has shown that to get
men into services requires enormous efforts to transport men to the services or to bring
services closer to men and this remains a funding gap. The request therefore also includes
support for mobile clinics to support community outreach which will augment PEPFAR
support.
This intervention will contribute to the increased number of males circumcised from
15,000 in 2015 to 21,000 by 2018.
Module on Prevention for MSMs and TGs:
Customised prevention interventions targeting most-at-risk populations are limited and
service uptake remains low. The BSS (2010) found that HIV risk perception among this
population is low. The country will be improving access to more effective and acceptable
comprehensive HIV services for key populations with the aim of increasing coverage and
to address current inequities in access. Through support from PEPFAR, the country is
currently in the process of determining current population sizes of key populations in
order to inform targeting and coverage levels of programmes. Through UNDP support, the
country is also conducting a Legal Environmental Assessment, which will inform
interventions aimed at addressing social and legal barriers to universal services.
In line with this, Global Fund support is requested for the training of 133 (one per facility)
health care workers drawn from public health facilities on providing acceptable nondiscriminatory comprehensive HIV services for key populations in a bid to remove barriers
to access to health services and guarantee their rights to access to services.
GF support is requested for the training of 100 MSM peer educators will provide peer-topeer risk reduction education and counselling, condom promotion and distribution. This
will be done utilizing the structured approach outlined in the SBC section to ensure
harmonization of approach. The estimated reach of each MSM peer educator is 32 people
per. To complement this, HC3 will provide mentorship for organizations and peer
educators to strengthen monitoring and reporting.
The expected outcomes are the increased perception of risk, increased access, distribution
and use of condoms, increased access to services as well as increased capacity of the
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healthcare workers to provide non-discriminatory services.
Module on Prevention for sex workers and their clients:
The BSS 2010 found that whilst sex workers reporting condom use with paying clients was
high at 80%, condom use with non-paying clients was low at 50%. The BSS also noted
though that the transition from regular to non-paying can be fluid and difficult to define.
With an average number of clients between 1-5 clients per week, this indicates this
population remains at high risk of HIV infection. The need to also ensure sex workers are
brought into care and reached with HIV interventions is prioritized in the eNSF.
GF support is requested for the training of 150 sex worker peer educators per year who will
provide peer-to peer risk reduction education and counselling, referral cards for STI
treatment, condom and lubricants promotion and distribution. This will be done utilizing
the structured approach outlined in the SBC section to ensure harmonization of approach.
The expected outcomes are the increased perception of risk, increased access, distribution
and use of condoms as well as increased access to services. It is anticipated that these
trained peer educators will reach 57,600 people per year.
Module on Prevention for Mobile Populations
The SHDS (2007) presented that men and women who spend more time away from their
home are likely to engage in risky sexual behaviours such as multiple concurrent sexual
partners. Factory workers, cane cutters (seasonal workers), transport operators,
construction workers and uniformed forces are identified in the eNSF as mobile
populations. The results of the BSS noted that HIV prevalence among textile workers and
cane cutters is 30.4% and 50% respectively. The Swaziland Business Coalition on HIV and
AIDS through support from corporate institutions in the sugar belt and in the construction
sector will be scaling up implementation of extensive HIV prevention and treatment
programs targeting cane cutters and construction workers. Interventions targeting factory
workers and transport operators remain limited and as such
Global Fund support is requested for the training of 150 peer educators among textile
workers (78 to be drawn and deployed in the Matsapha industrial area) and transport
operators (72 drawn from each of the 12 towns) who will be responsible for risk reduction
counselling, condom promotion and distribution and referral to STI and HIV services.
Based on the PSI benchmarks for peer educator reach, it is estimated that these peer
educators will reach 57,600 textile workers and transport operators per year.
The expected outcomes are the increased perception of risk, increased access, distribution
and use of condoms as well as increased access to services.
PMTCT Module:
The national PMTCT program data shows that only 3% of children born to HIV positive
mothers are infected with HIV at ages 6-8 weeks. The country will accelerate the roll out of
option B+, to all pregnant and lactating women in order to strengthen the PMTCT
program. However, follow-up of mother-baby pairs and ART adherence of pregnant HIV
positive women has historically been a challenge that has resulted in new infections among
children at a rate of 11% post 8 weeks. This is due to breastfeeding practices, loss to follow
up post the 8 weeks and low uptake of ART among eligible mothers. The request to the
Global Fund is therefore to scale up provision of care and support to HIV positive mothers
through mentor mothers who will identify pregnant and lactating mothers, refer them to
services using the Facility-Community referral tool, track and follow them up to provide
support for disclosure, nutrition education, adherence counselling and family planning.
The expected outcome of this intervention is the provision of continuum of care post 8
weeks where more mothers will be retained in care which will in turn impact maternal
mortality, reduction of HIV transmission to infants from 3% in 2014 to 1% in 2018 and
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identification and linkages to care for HIV positive children.
Treatment care and support Module:
Rationale
The country is looking at scaling ART coverage, this will partly be met by adopting the
2013 WHO recommendations on use of ARVs for HIV prevention and treatment. Through
partners (MSF and MaxART Consortium), the Ministry of Health is conducting pilots on
the feasibility, acceptability, cost-effectiveness and scalability of “test and treat”
approaches for provision of ART to the general public. This should inform the country
moving forward on how to roll out these modalities if they prove to be effective. With this
background, the strategies and activities selected for this concept note were prioritized
based on the gaps identified in the programmatic and financial analyses.
Expected impact and outcomes
Scale up of ART provision: ART provision in Swaziland is highly decentralized. ART
initiation services are available at the primary health care level and comprehensive ART
services are available in more than 80% of all public facilities and encompass all the major
private facilities. Rapid ART scale under the new approach will strain service delivery at
these facilities despite the widespread decentralization of services, hence the deliberate
move to shift tasks and certain services to the community to decongest health facilities and
accommodate the rapid increase in patients requiring ART. Modalities to provide ART in
the community for stable patients are currently being piloted and will inform the country
on what is feasible, acceptable and possibly a best practice that can be adopted and scaled
up.
Studies have shown that ART can protect against HIV transmission (96% protection) at
the individual level (HPTN052) and with adequate ART coverage across the country, can
potentially impact incidence at the population level. A combination prevention strategy
that includes wide spread ART coverage with the other core prevention programmes (see
1.2) could help the country achieve the High level Meeting (HLM) targets of halving new
cases (incidence). The impact of ART on mortality related to HIV and the benefits patients
receive in terms improved quality of life are well documented. Global fund support will
help the country meet these goals and maintain the gains the country has made since the
start of ART program.
The main output of this intervention is, at least 80% of all PLHIV will be on ART by 2018.
This level of coverage can be achieved by enrolling 90% of people in need of ART based on
current WHO recommendations. ART coverage can potentially reduce the risk of an HIV
negative person acquiring HIV, living in a community were ART coverage is 30-40%
reduces risk of acquiring HIV by 38% compared to a community with <10% coverage,
holding with other conditions held constant (Tanser et al.). Though ART provision is being
scaled up, patients with CD4 less 350cells/mm3 will be a priority and the target is 95%
coverage in this population. Median CD4 at ART initiation is 236 (Annual HIV report
2013) suggesting that patients still present late for treatment and this will continue to be
monitored.
Scale up of viral load testing: For improved treatment outcomes, routine viral load
monitoring for all patients on ART as a standard of care is essential. Introduction of
routine viral load monitoring will change the approach from the current targeted viral load
testing for specific patients who are failing treatment immunologically and/or clinically to
all PLHIV on ART receiving regular viral load testing. Implementation of routine VL
monitoring will see an increase in testing from the current 13,000 tests per year to
approximately 115,000 tests by 2015.
There will be a need to boost the current human resource available in the molecular
laboratory at the NRL. This will allow the laboratory to meet the testing needs of the scale
up. With scale up of viral load testing there will be a concurrent scale down of CD4 testing.
This will result in cost savings that will be moved to support viral load testing and will also
free up laboratory technologist effort and allow this to be redirected to viral load testing. It
is also anticipated that the number of viral load tests done at central level will decrease
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over time as there is a great possibility that point of care viral load testing will be availed
and rolled out. The government has also shown commitment in absorbing health staff
funded donors especially if they are aligned to the government establishment.
Diagnosis of treatment failure will be made quicker and adherence challenges will be
addressed promptly. This will help limit the development of resistance among the general
population and those patients requiring a switch to second line will be switched early and
will not remain on a failing regime for too long (Promotes development of Thymidine
Analogue Mutations (TAMS) for patients on AZT and d4T). The proportion of patients on
second line will most likely increase, as more patients who are failing treatment will be
identified. With better management of patients with elevated viral loads, we expect to
achieve 90% viral suppression in patients on ART by 2017. Generally we expect a marked
improvement in the quality of care provided especially regarding regimen selection and
diagnosis and management of treatment failure.
In addition to support for viral load scale up, support in the procurement of haematology
and chemistry reagents to cope with scale up of ART provision will be essential as this will
allow the country to provide quality HIV services as ART initiation is scaled up. Current
first line regimens used are TDF and AZT based, with EFV and NVP as the preferred
NNRTIs, therefore the possibility of toxicity (anaemia and renal/liver dysfunction) is
significant, highlighting the importance of monitoring these parameters in all patients
initiating ART. Toxicity contributes to attrition (patients stopping treatment) and leads to
regimen alteration, which affects adherence, overall retention in care and costs of
treatment.
Monitoring HIVDR: Swaziland has a mature ART program that is more than 10 years old
with about 4% of patients currently on second line ART (Program data). HIVDR
monitoring and surveillance is a critical component of the public health approach to ART
provision. It informs program level decision-making with regard to optimization treatment
regiments. By reducing HIVDR the country maximizes the durability of first line and
ensures sustainability of the ART program.
Request above allocated amount
Nutritional Support: Support from global fund will allow the country to reach 37,775
patients in need of nutritional support over the next 3 years. Approximately 11% of patients
initiating ART in Swaziland are malnourished (based on BMI and MUAC measurements).
In addition 33% of Tb patients are malnourished and are addressed in this request because
of the high TB/HIV co-infection rate in Swaziland (80%). Attrition related to malnutrition
(Loss to follow up and death) is highest with the first 3 months of ART initiation. Limited
availability of nutritional supplements (not available at the primary healthcare level) has
affected the decentralization of ART services as patients prefer to stay in the facilities were
food supplements are available rather than accessing services in the primary health care
clinics with in their communities. Rolling out food by prescription nationally will promote
decentralization, adherence to treatment and overall improved retention in care. This also
feeds into the broader picture of achieving greater than 90% viral suppression and a
reduction in new cases of HIV.
------------------------------------------------------------------------------------------------------TB Program
TB Program
Swaziland has made major strides in expanding access to rapid TB diagnosis and
appropriate treatment initiation through the adoption of GeneXpert MTB/RIF as an initial
diagnostic test and the decentralization of TB peripheral laboratories and treatment
initiating sites. However, challenges remain with the declining TB case notification rate
and low treatment success below the global (WHO) and NSP set target. This formed the
basis for prioritization of interventions to increase early TB case detection as well as
improvement of the treatment success rate as envisioned in the current NSP (2015-2019).
Goals and objectives of the NFM funding request:
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04Nov 2014│ 77
The main goal of this funding request is to contribute to the reduction of the TB, TB/HIV
and DR-TB burden in Swaziland in line with the national and global TB targets.
The strategic priorities for this funding request aim to: expand the TB laboratory network,
facilitate access to timely initiation of TB treatment, expand access to integrated TB/HIV
services through a one-stop shop model, address the declining TB case notification rate
and establish accurate levels of drug-resistant TB, strengthen programmatic management
of drug-resistant tuberculosis (PMDT) and optimize the role of existing community
systems in TB control through empowerment.
Caveat: Given the country’s declining case notification rate set against the WHO model
estimates and the lack of concrete evidence on the country’s background epidemiology, the
targets set in the TB NSP (2015-2019) are subject to revision following the conduct of a TB
Prevalence Survey in 2016 which will provide an evidence-based review of the country’s
true burden of disease.
Rationale for selection of TB service delivery modules
The selection of modules and interventions in this proposal request has been informed by
key gaps and priorities outlined in the new National TB Strategic Plan. There are three core
(service delivery modules) prioritized in this request, namely; TB Care and prevention;
TB/HIV and MDR-TB. The detailed programmatic gap analysis for each of the core
modules is as described in the online platform. The rationale for selecting these three core
modules is as follows;
a) TB Care and Prevention module
Given the sub-optimal estimated case detection of TB in our context, 46% in 2012,
interventions to find additional cases throughout the lifespan of the new strategy is an area
of priority focus. The true burden of disease remains unknown and current estimates are
based on WHO modelled estimates. However, there are plans under the NFM to conduct a
TB Prevalence survey in 2016, which will provide accurate information regarding the TB
disease burden in Swaziland. In addition, case holding of patients in care to optimize
treatment outcomes has been prioritized, as current achievements still lag behind global
achievements and national targets (76% Treatment success rate in 2013). The funding
request will prioritize high impact interventions such as strengthening Active and
Intensified Case Finding, further expansion of the peripheral laboratory network and scale
up of GeneXpert MTB/Rif and digital radiology to improve case detection of EPTB and
childhood TB. It is anticipated to compliment domestic funding to improve case detection
from 46% currently to at least 70% by 2017, and improve treatment success to 90% by
2019.
b) TB/HIV module
The TB epidemic in Swaziland is predominantly driven by HIV with an 80% TB/HIV coinfection rate. While gains have been registered in HIV testing among TB patients and CPT
uptake, access to ART for TB patients co-infected remains challenged (75% in 2013).
Interventions to optimize coverage through rollout of more patient-centred “one-stop
shop” TB-HIV clinics and consolidate current gains justify the need to prioritize this
module in this request. The funding request will compliment commitments from the TB
NSP and domestic resources to achieve ART access targets for co-infected patients of 100%
by 2017.
c) MDR-TB Module
The emerging threat from drug resistant forms of TB continues to undermine gains in TB
control efforts. The true burden in our context remains unknown and current estimates are
based on the last drug resistant survey done in 2009. There are plans however under the
NFM to conduct a drug resistant survey that will refine current estimates. With progressive
scale up of Xpert MTB/Rif, there has been a sustained increase in case detection of
resistant forms of TB. In 2013, 433 cases of Drug resistant TB were detected, compared to
196 in 201211. In spite of such notable gains, case detection for drug resistant TB remains a
challenge and there still remains a significant treatment access gap resulting from a highly
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centralized system. The funding sought will enhance community-based MDR-TB case
management through further decentralization of DR-TB services to optimize case
detection and close the treatment access gap, justifying the selection of this module for
funding.
Rationale for prioritization of Interventions:
The selection of interventions in this proposal request has been informed by key gaps and
priorities outlined in the TB NSP (2015-2019). This has been the product of the WHO
NTCP external review which included a situational analysis, review of outgoing NSP (20102014) and consultation process with all stakeholders in the country and include the
following;
1. TB care and prevention module (including Program Management and
M&E)
Strengthening intensified and active case finding are priority areas of the new strategy. The
goal is to diagnose and enrol on treatment at least a total of 40,000 TB cases by 2019 and
achieve a 35% reduction of TB prevalence rate by 2019 to 907/100,000 of 2013.
In addition, ensuring continuation of patient care to optimize treatment outcomes has
been prioritized, as current achievements still lag behind global and national targets.
Allocated funding
Globally and in-country there has been significant improvement towards realization of a
decline in TB cases including Swaziland where a TB Prevalence survey has been prioritized
to facilitate accurate estimation of the true burden of disease, especially in view of a
declining case notification rate against increasing WHO modelled estimates of incidence.
In addition, the country has not in the recent past conducted a TB prevalence survey,
therefore, current targets as set in the TB NSP (2015-2019) are subject to revision based of
the evidence generated from the proposed TB Prevalence Survey. To address the declining
case notifications, the country has prioritized a nationwide scale up of active and
intensified case finding activities aimed at bringing TB screening and testing services
deeper into communities most at need and yet with the most challenges to healthcare
access. This includes conducting community awareness and social mobilization campaigns
with the support of a mobile TB clinic, equipped with a GeneXpert MTB/RIF unit and
digital Xray, to provide TB screening, onsite diagnosis and treatment initiation of key
populations in under-served, hard to reach areas, congregate settings (mines) and TB hotspots. The mobile outreach services will initially focus on high TB/HIV burden
communities with limited access to diagnostic and treatment facilities. Once diagnosed
and initiated on treatment, patients will be linked to nearest facility for continuation of
therapy and treatment support by Rural Health Motivators. TB might be the entry point
for this service but integration with other health services will be maintained e.g. NCDs,
ANC, PMTCT, and EPI. Campaigns will be conducted on a rotational basis in regions in
collaboration with the regional and community health structures to facilitate uptake and
acceptability.
In addition to the community campaigns for demand creation, there will be an ongoing
activity of on-the-ground Active Case Finders in each chiefdom to conduct nationwide
door-to-door TB screening and testing as many people (especially those with immunecompromised systems –PLHIV, children, ex-miners) with active TB do not experience
typical TB symptoms in the early stages of the disease. These individuals are unlikely to
seek care early, and may not be properly diagnosed when seeking care. This and other
cultural, religious and stigma barriers along the patient-initiated pathway leads to missed
or delayed TB diagnoses. In addition, problems with access to high-quality care lead to a
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higher risk of death, suffering, sequelae and catastrophic financial consequences. These
missed opportunities also lead to a longer duration of infectiousness for individuals, and
thus sustain community transmission, especially where population density is high and
where living and working conditions are poor, including conditions that are overcrowded
and have inadequate ventilation. Therefore, successful implementation of the community
ACF strategy as described below is expected to reduce the pool of undetected TB cases
remaining despite the scaling up and decentralizing of TB diagnosis and treatment,
thereby reducing the risk of poor treatment outcomes, health sequelae, and the adverse
social and economic consequences of TB for the individual. This will reduce suffering, the
prevalence of TB, and death from TB as well as reduce TB transmission by shortening of
the duration of infectiousness and hence reducing the incidence of TB infection and
consequently contribute to reduced incidence of TB disease.
Swaziland legislatively has 55 Tinkhundla from which parliamentarians are selected by the
constituencies for national representation. Out of these Tinkhundla, there exist 369
chiefdoms each with a radius of approximately 46 km radius on average. Each chiefdom
has approximately 300 homesteads with on average 10 people per homestead. Therefore
369 Active Case Finders will be recruited, equipped with a basic mountain bike each and
allocated a chiefdom to conduct TB screening and HIV sensitization (IEC material and
condom distribution) of 2 homesteads per day. Clients who screen positive for TB will have
their samples collected on the spot and transported to the community clinic, by the Active
Case Finder on their customized bicycle, for testing at the nearest peripheral laboratory.
The National Sample Transportation System (NSTS) will transport samples from clinics to
laboratories and return with results. As each Active Case Finder is attached to the
community clinic serving that chiefdom as a catchment area, they will alert patients to
attend the clinic for feedback of results and possible treatment initiation if required.
Clients will be referred to the clinic and linked to HIV Expert Clients for HCT.
The unique opportunity to screen and test clients at home will enhance access to disabled
people, women, children, PLHIV and MSM who otherwise are unable to seek health
services for cultural/religious reasons or fear of stigmatization and victimization. The
target is for each Active Case Finder to test an average of 5 people per homestead and 2
homesteads daily. With a 10-15% TB screening and testing positivity rate, this aggressive
active case finding strategy is estimated to yield an additional 4000 TB cases annually.
The program will conduct regional sensitization workshops for all the chiefs on the ACF
strategy to empower communities and facilitate community engagement. The Active case
finding will be engaged through community leaders for acceptability and ownership. They
will report monthly to the chiefdom inner council monitor progress, address acceptability
and mobilize communities to take up services. This will foster empowerment as well as for
the purposes of acceptability and ownership of the services by the community.
Active Case Finders will submit formal monthly reports to Primary health care clinics.
Case finders will report weekly to the clinic to meet with facility staff and Adherence
officers who in turn report to Regional TB/HIV Coordinators. Regional Health
Management teams (RHMTs) are responsible for the overall management structure and
oversight in the regions and the TB/HIV Regional Coordinators are members for active
support of community initiatives. RHMTs conduct monthly meetings attended by Regional
coordinators for reporting of TB activities and to advocate for support.
The TB programme is currently undergoing massive expansion of TB treatment initiating
services by decentralizing Basic Management Units (BMUS) in a stepwise approach, from
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86 BMUs currently to 145 by 2019. Additional Cough Officers are critical to successfully
expand and strengthen TB ICF and systematic screening activities to improve TB case
detection in health facilities not initiating TB treatment. The current 40 cough officers
have been strategically deployed to Hospitals, health centres (entry points OPDs, PMTCT
sites) to conduct systematic TB screening for all patients and additional Cough Officers are
required to maintain these gains and scale up on the number of cases detected.
In line with further decentralization of TB services to lower levels, the NTCP plans to
expand intensified TB case finding to Primary health clinics. Worth noting is that the
Primary health clinic provide integrated services under one roof which include but not
limited to EPI and minor ailments for under-fives years. Hence this would be an
opportunity to offer TB services particularly TB screening for this key population. The
Primary health clinic also provides Antennal care (PMTCT) and family planning services.
Under the current arrangement TB screening for pregnant women is confined to public
health units (PHU). The plan is to scale up TB screening to lower levels clinics who provide
the same services as PHU and also have an added advantage of being within the
communities to target this key population and limit mother-to-baby TB transmission.
Additionally, to address TB diagnosis and management for patients with co-morbidities in
patients, e.g. diabetes, the program plans to rollout TB screening in NCD clinics, which are
attached to hospitals and health centres. This is an opportunity for the program to
maximize case finding and linkages to TB/HIV care. The samples will be collected and
transported through the National Transportation system to TB laboratories.
Intensified case finding (ICF) and contact tracing within communities using GF supported
Treatment supporters and Adherence officers will be strengthened in line with existing
community structures i.e. RHMs, Banakekeli etc. Included in the funding request are
additional motorbikes to facilitate contact and defaulter tracing by the Adherence Officers.
The NTCP has adopted innovative methods of outbreak investigation and contact tracing
with the use of GIS mapping of GPS coordinates for all DR-TB patients with electronic
monitoring of these patients. The funding request includes procurement of additional
Garmin tracking devices as more patients are diagnosed.
Strengthening the Public-Private Mix coordination through Swaziland STOP-TB
Partnership (SSTP) and engaging all private care providers (e.g. Traditional Healers,
NGOs, Faith-Based Organisations etc.) will greatly assist in harmonizing the quality of TB
care provided to the 30% of the Swazi population who prefer not to seek public healthcare
services (SSTP Mapping exercise, 2007). Strengthening community TB engagement
activities as well as engagement of Civil Society (CSOs) and Community structures (e.g.
Traditional healers, CBOs, Chiefs) is critical for community buy-in and mobilization.
Based on the current national TB diagnostic algorithm, which recommends use of Xpert
MTB/Rif for initial TB diagnostics among all presumptive TB cases (regardless of HIV
status or previous TB treatment history), together with intensified activities to increase the
case notification rate, the number of Xpert tests conducted annually is expected to increase
significantly. The NFM funding request will procure the required number of GeneXpert
MTB/RIF cartridges to support the rapid diagnosis of cases and one BACTEC MGIT960
system to meet the demand of compulsory culture and First-line DST (FLD) for all MTB
positive patients as per the national TB diagnostic algorithm. Funding support for culture
testing reagents is also included in the NFM to ensure an uninterrupted supply of critical
laboratory supplies and commodities required for quality diagnosis and treatment
monitoring of both DS-TB and DR-TB.
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Ongoing support of Global Fund with GeneXpert MTB/RIF cartridges and laboratory HR
as well as training has greatly assisted in decentralizing diagnostic services to lower level
facilities. There are now a total of 25 Peripheral laboratories each equipped with a
GeneXpert MTB/RIF 4-module unit, a BioSafety Cabinet and a full-time TB Microscopist
supervised by the NTCP Laboratory focal person. FLD services have been available in the
country since 2010 and the NTRL has since been upgraded to BSL3.The country is in the
process of introducing Second-line DST (SLD) facilities and TB Lab Technologists are
undergoing intensive training on conducting SLD as this service has not been provided to
presumptive XDR-TB patients since 2012. Continued support for laboratory HR to
conduct FLD and SLD through the NFM grant will be critical.
Childhood TB has been neglected globally and Swaziland aims to address this by
prioritizing Childhood TB case detection, diagnosis and management. The country intends
to increase detection of TB among children by integrating TB screening at ANC and MNCH
clinics. This includes engagement with other childcare services to capacitate and
strengthen the integration of diagnosis and care for childhood TB at different levels of the
health system. To support this effort health care worker will be trained on childhood TB
care, including use of digital radiography, Xpert MTB/Rif, and approaches to obtain
biological specimens for Xpert MTB/Rif testing as well as implementation of INH
Prophylactic Therapy (IPT) for children under 5 years.
With the current sub-optimal treatment outcomes of 76% treatment success, there is need
to strengthen patient-centred community based care, to support systematic contact
investigation, treatment adherence support and retrieval of patients lost to follow up.
Funding through the NFM grant will be used to strengthen community TB care to ensure
wider coverage as well as strengthen coordination of community activities. The NTCP will
engage all RHMs trained under the current HSS grant, to contribute to community TB
activities in collaboration with supported CSOs, particularly with the provision of
treatment adherence and support services to drug susceptible patients. Each of the 5000
RHMs will be assigned to a DS-TB patient for the duration of their TB treatment (and ART
where necessary) although as case detection increases, two or more patients will be
supported per RHM. The RHMs will also be engaged to assist during community
awareness and social mobilization campaigns, provide integrated TB/HIV screening,
testing and contact tracing services as well as distribute condoms (male and female) and
HIV IEC material distribution. The R10 grant has also provided critical support of DR-TB
Community Treatment supporters and Adherence Officers, who provide contact tracing
and defaulter tracing services in close collaboration with facility staff and Regional
TB/HIV Coordinators. The NFM includes ongoing salary support of these cadres.
This is in line with the TB models of care implemented by the country, which is Facility
and Community-based management. The Community-based HCWs will play a major in
DOTS implementation in terms of awareness, active case finding, monitoring and
supporting patients on treatment resulting in desirable case notification and treatment
success. The CHCWs will be linked to health facilities for supervision to provide accurate
and timely reports, early detection, timely treatment initiation and adherence to
treatment. The Community service coordinator and DOTs coordinator will provide support
and supervision at national level and will work closely with Regional TB/HIV Coordinators
to strengthen the community health care interventions particularly integrated trainings
and monitoring of community based activities. Regional TB/HIV Coordinators supervise
and monitor successful implementation of TB services in facilities and communities within
their region and report to the National DOTs and TB/HIV Coordinators. TB control
services will be implemented as follows (from the lowest level to high level);
Swaziland TB and HIV Concept Note
04Nov 2014│ 82
Community level
Active Case Finders will be assigned each to a chiefdom with approximately 300
homesteads in each chiefdom within the clinic catchment area to conduct active case
finding and contact tracing activities. RHMs (5300) will conduct treatment support, joint
TB/HIV screening and testing as well as contact tracing, while the DR-TB Community
Treatment supporters conduct treatment adherence and support to MDR-TB patients and
contact tracing/screening services to household contacts. To support these activities, they
will be trained on integrated TB/HIV case detection and management as they will screen
all household members, test those who screen positive for TB and refer to the nearest clinic
for treatment initiation. RHMs will also provide HIV testing and counselling. Treatment
support is provided for both TB and ART adherence for the duration of TB therapy. These
cadres liaise very closely with facility staff, Adherence Officers and Regional TB/HIV
Coordinators. They meet weekly with Adherence Officers and submit monthly reports to
the health facility.
Clinic level
Cough officers: The Cough officers screen all patients at all entry points in high volume
health facilities (hospitals and health centres) to conduct intensified case finding and
systematic screening of all patients presenting to these facilities whether symptomatic or
asymptomatic. Cough Officers report to the health facilities and are supervised by and
report to the nurses. They also work in closely with the RHMs, DR-TB Treatment
Supporters and Adherence officers on contact tracing, feedback of results and defaulter
tracing.
Hospitals and health centres
Adherence officers supervise community HCWs and play a critical role in linking hospitals
and health centres to the smaller satellite clinics within the community catchment area.
They transport samples from the community clinics to the hospitals/health centres and
feedback results from the laboratory. Defaulter tracing by the adherence officers occurs
from two angles: 1. Facility staff notifies them of patients who have defaulted treatment,
and, 2. The DR-TB Community Treatment supporters, Active Case Finders and RHMs will
alert them of patients who have defaulted treatment. Adherence officers are supervised by
the Regional TB/HIV Coordinators and report monthly to the hospital/ health Centre and
the coordinators. They play a vital role in adherence support of TB/HIV co-infected
patients.
TB Health Information Systems (Monitoring and Evaluation) activities
The prioritized activities require strong support from the M&E unit in order to meet the
expected impact and output targets (caveat: The TB NSP targets are based on WHO
modelled estimates and therefore subject to revision following evidence generated from
the proposed TB Prevalence Survey). The prioritized activities to facilitate quality
recording and reporting of TB data from the community level to national level include
intensive training of all healthcare workers and patient support staff (Active Case Finders,
Treatment supporters, Adherence Officers, Cough Officers, RHMs etc.) as well as
conducting monthly supportive supervision visits with thematic leads (National M&E
officer, National TB/HIV Coordinators, NTRL Manager, National DOTS Coordinator,
National IPC Coordinator and National MDR-TB Coordinators) to ensure maintenance of
quality assurance and improvement of patient care. The funding request includes support
for M&E capacity building and regular supportive supervision visits.
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Data quality improvement and assurance is critical to facilitate evidence-based decisionmaking. The program will conduct National and Regional Quarterly Review meetings to
enhance the understanding and ownership of TB data, without which a program cannot
evaluate its performance to inform quality data review. External programme reviews have
been used to monitor and evaluate implementation of the National Strategic plan and also
to inform the revision of the National TB/DR-TB management guidelines, in this vein a
joint TB/HIV mid-term external program review will be conducted in 2017 to inform joint
programming and further alignment of programmatic activities.
TB Program management activities
Enhancement of the coordination functions of the NTCP at national and regional levels is
key to successful implementation of the country’s NSP 2015-2019. The current grant has
been supporting salaries for key staff at national level and although some positions have
been absorbed into the government establishment, it is unlikely that domestic resource
will retain and sustain all NTCP staff support. Continued support for these positions will
be crucial to safeguard current gains in service delivery. The funding requested will
support staff salaries of national, regional and community level staff as well as critical
laboratory staff at the NTRL and peripheral laboratories. This is in line with the NSP 20152019 and the Global Stop TB Post 2015 strategy.
In addition, the need to re-enforce consistent and systematic support supervision and
mentorship is considered critical to ensure continuous quality improvement of patient
care. Part of the allocated funding is therefore proposed for mentorship visits, support and
supervision at all levels. Regular technical coordination meetings across different levels of
service delivery are important to ensure harmonization in the application of national
policies and guidelines. Such meetings provide the platform for reviewing programme
implementation and interrogating key bottlenecks in service delivery; as well as
communicating technical updates. Funding is requested to support technical coordination
meetings at national and regional level, as well as PMDT and M&E trainings to facilitate a
learning organisation.
It is proposed that the implementation arrangements for this funding request are to be
selected by the CCM. Grant management costs for the PR/PRs have been allocated.
Above Allocation
The activities proposed for funding through above-allocation funding are those considered
as potentially high impact in the context of Swaziland and by no means less prioritized.
The selected activities are priority towards improving TB case detection/notification and
the treatment success rate. Therefore, the ongoing decentralization of TB laboratories
through the upgrade of mini-laboratories is critical to support TB diagnostic services in the
country. Furthermore, a total of 11 peripheral laboratories will be targeted for
infrastructure improvements to meet minimum biosafety standards and will entail
installation of appropriate laboratory work benches, sinks, shelving, extra windows and
extractors as appropriate for infection control. This will facilitate the intended expansion
in diagnostic services and does not involve destruction/construction of any structure.
In addition, vehicles have been requested for use by the M&E and DOTs teams to conduct
weekly on-site community and facility mentoring visits and the above-mentioned
activities. In addition, two cars are requested to facilitate Program Management and
coordination of the upcoming Prevalence and Drug Resistance Surveys.
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04Nov 2014│ 84
With this funding, the NTCP is bolstering its passive and active surveillance system, which
is the most effective way to address the ongoing importation challenges and assist in
achieving the elimination goal. Disease surveillance is critical for successful management
of programs and funding is requested to develop a disease surveillance model and manual.
This system and ETR are different from the CMIS, as the latter cannot accommodate all
the necessary TB data variables required for patient monitoring and ongoing statistical
analysis/data review.
According to the WHO Epidemiological Analysis conducted during the external program
review in April 2014, there is gross under-reporting of childhood TB cases in the country as
the ratio of age groups 0-4yrs (n=359) to 5-14yrs (n=312) is 1.15, which is below the target
range of 1.5-3.0. In addition, no national inventory study has been conducted to assess
completeness of reporting for childhood TB cases in the last 10 years. This informed the
prioritization of childhood and adult TB inventory studies in the NFM concept note.
Successful implementation of the above-mentioned interventions will greatly assist in
increasing the current case detection and treatment success rates to 70% and 90%,
respectively.
2. TB/HIV collaboration module
TB/HIV collaborative services are in the process of scaling up. Mechanisms of
collaboration have been set up at national level and are currently being decentralized to
regions with plans to further decentralize to lower level facilities. This is critical as in
Swaziland, HIV is the main driver of the TB epidemic. According to the NTCP 2012 annual
report, 95% of detected TB patients were tested for HIV of whom 80% were HIV positive.
The same report estimated that 98% of HIV-positive TB patients were on CPT and 66% of
HIV-positive TB patients were on ART. It is vital to note that TB/HIV activities are
embedded within the joint implementation of the TB and HIV Programmes. Therefore,
activities listed under this module are not the only activities prioritized by the Programmes
to address TB/HIV collaboration. In addition to these coordination activities for which
funding is requested are collaborative activities already fully funded under the
governments TB/HIV budget to address TB/HIV activities to reduce the burden of TB in
PLHIV (3Is) and HIV in TB patients.
Within Allocation
Funding is requested to support strengthening of the National TB/HIV Coordinating body
to be functional at all levels of the healthcare system (national and regional) to provide a
platform for the implementation of TB/HIV collaborative activities as well as developing
and disseminating key TB/HIV messages to communities. Funding is also requested to
support annual joint TB/HIV planning meetings to facilitate annual data review and
planning. This includes in settings like the mines and uniformed service establishments,
infection control will be enhanced through targeted training of health workers in their
institutions. On the other hand, in informal mining settings (especially among the migrant
miners based in neighbouring countries), infection control will be re-enforced through
training of selected CSOs, who will in turn cascade trainings to peer educators for infection
control sensitization in informal congregate settings.
Healthcare workers are at high risk of contracting TB and protecting them is important
and GF has been supporting PPE implementation at facilities. This support is requested to
continue in the NFM.
Above Allocation
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04Nov 2014│ 85
The NFM funding request will complement the World Bank TB IPC infrastructure
refurbishment project with the provision of prefabs, sputum booths, Hepa filters and
UVGI lights to 45 non-IPC compliant facilities not earmarked for major infrastructural
repairs. The requested NFM funding will support the following activities: Strengthening
referrals systems and diagnosis at the PHUs to facilitate provision of comprehensive
TB/HIV services, Conduct pre-service training attachment for HCW on TB/HIV
management and Conduct joint supportive supervision and mentoring to HCW working in
TB/HIV management settings and strengthening of the integration of TB services in the
management of non-communicable diseases.
3. MDR-TB module
Diagnostic capacity for case detection of drug resistant TB remains limited, despite
ongoing efforts to roll out rapid molecular technology (GeneXpert MTB/RIF). In 2013,
only 39% of MTB positive cases were investigated for drug resistant TB on culture and FLD
while no confirmed MDR-TB cases were tested for resistance to Second-line drugs.
Equally, treatment outcomes among DR-TB cases are sub-optimal (56% in 2010 cohort).
The selected interventions seek to increase public knowledge on MDR-TB, strengthen
laboratory capacity for DR TB case detection; as well as building institutional and
community capacity for case management to optimize treatment outcomes and minimize
disease transmission.
Within Allocation
The country is currently faced with the increasing threat of drug-resistant TB with levels
among new cases (8%) more than double the regional average (3%) and levels among
previously treated TB patients (34%) three times higher than the regional average (12%).
The last Drug Resistant Survey was conducted in 2009 and funding support will be
requested in the NFM to conduct a repeat DRS which will facilitate evidence-based
decision-making on DR-TB surveillance. Community sensitization and public health
education on MDR-TB and IPC is critical for successful PMDT. The funding request will
enable conducting awareness campaigns on MDR-TB specifically focusing on key
populations e.g. miners, ex-miners, children and prisoners.
The national capacity for DR-TB diagnosis and treatment monitoring will be strengthened
through sustained procurement of reagents for both 1st and 2nd line molecular DST as
well as procurement of a BACTEC MGIT 960 system with a service contract. This
MGIT960 system will replace a currently system which is unable to facilitate to full
capacity due to frequent break down of two drawers. The introduction of the new
diagnostic algorithm to include culture testing for all MTB positive which will increase the
number of samples.
Decentralization: DR-TB management
As part of the efforts towards improving the management of DR-TB in the country, the
National Tuberculosis Control Programme (NTCP) has decentralized the management of
DR-TB in line with the national TB control strategy and the DR-TB Decentralization Plan
developed in 2010 and currently in implementation. Thus far DR-TB Management has
been decentralized from 1 central unit (TB Referral Hospital) to currently 8 DR-TB Reginal
facilities. In the same period, treatment outcomes improved from 33% to the current 58%.
The plan clearly defines the concept of decentralization in the context of DR-TB
management, the rational for the decentralization, minimum package of DR-TB services
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04Nov 2014│ 86
for the different service delivery points, key steps and requirements for decentralization.
The plan aims to provide guidance to all stakeholders, including implementing partners,
on the entire process of decentralization. Decentralization in the context of DR-TB
management herein, refers to provision of specific DR-TB related services, including
diagnosis, treatment care and support at the different levels of the national healthcare
system (National, regional and community levels). The aim is to bring these services as
close to the people in need as possible. This hopefully would contribute to an increase in
case detection rate, case holding, treatment success and health system strengthening.





Rational/reasons for decentralization of DR-TB services
To bring DR-TB services closer to those in need
To remove access barriers to DR-TB services. Current centralized approach to
management of DR-TB TB in the country has the potential of limiting access to
prevention, treatment care and support services/activities, as most patients from
different parts of the country have to travel to Manzini for treatment and reviews
To maximize utilization of existing limited resources
To allow for involvement of different stake holders with diverse skills including
community members, in the management of DR-TB
To strengthen the community component of the DR-TB programme. This at the
moment may be considered weak.
Guiding principles
The decentralization of management of DR-TB is done in a systematic and controlled
manner. A phase wise approach to the decentralization process is considered appropriate.
Systems and mechanisms that will ensure provision of high quality and standardized
services at the different service delivery points will also be put in place. These mechanisms
include:
 Use of a standard tool to assess all facilities for accreditation, development of
standard operational plans/procedures for provision of DR-TB services in all health
facilities, to ensure standardization of services.
 Continuous training of healthcare workers, including community healthcare
workers involved in the management of DR-TB
 Mentoring and support supervision to all health care workers at the different levels
 Monitoring of activities at different levels
 Putting in place quality assurance mechanisms at different levels of service delivery
Figure 2 Schematic diagram showing the key steps for decentralization of DR-TB services
1. Site
identification
2. Development of
facility specific
SOP
3. Assessment of
site for
accreditation
6.
5. Training of
health care
workers
4. Site Accreditation
Implementation
under close
supervision and
Further information on the decentralization process and organisation of DR-TB services
and minimum care packages is included in the attached DR-TB Decentralization Plan. The
decentralization of DR-TB Treatment initiating sites to an additional 5 facilities to meet
Swaziland TB and HIV Concept Note
04Nov 2014│ 87
the target of 13 DR-TB sites by 2019 is supported mainly by the Swazi government and
World Bank TB IPC Project with ongoing strengthening of the capacity of the existing GF
supported Regional clinical teams to provide continuous supportive supervision and
mentoring to facility staff whilst also conducting weekly community outreach visits. This
request will support capacity building of health care workers through training on PMDT to
ensure provision of quality care at regional and community levels. This will sustain current
gains in the decentralized care of DR-TB. Decentralization of MDR-TB services ensures
accessibility to services and also alleviates opportunity costs for patients.
The long-term strategy for management of DR-TB in the country is one which incorporates
both the facility and community-based models of care. However, successful
implementation of the community component requires a network of trained community
health workers, including family members, rural health motivators, community treatment
supporters and well equipped health facilities.
The functions of the community based care supporters include:
 Provision of community based DOT
 Early detection of serious adverse reactions and prompt referral to health
facility/HCW
 Provision of simple non-medical measures to manage adverse reaction
 Contact tracing
 Administration of injectables by retired nurses is still being considered for patients
on ambulatory care and without access to a nearby health facilities or for those
who are critically ill and living in hard to reach areas
 Educating family members and patients on simple infection control practices such
as cough etiquette, opening of windows etc. and assessment of risk factors
 Community based education and training on wide range of issues e.g. information
on TB, TB/HIV, DR-TB, infection control, importance of adherence etc.
 Social support; help identify socioeconomic and psychosocial needs of patients and
help in channelling support accordingly.
 Advocacy and decreasing stigma; through establishment of patient peer support
groups and local organisations
Psychosocial support to patients on treatment is considered an essential part of
comprehensive care, given the duration of 2nd line treatment and the related adverse
events or side effects, such as ototoxicity. Audiology assessments will be provided to all
patients on 2nd line treatment. NFM funding will be used to support the installation of
audiology equipment in DR-TB sites, train healthcare workers on Audio-screening and
provide hearing aids for affected patients. Funding support for DR-TB Community
Treatment supporters and the Regional MDR-TB Clinical teams is expected to improve
DR-TB quality of care, retention of patients and improved treatment outcomes. The
funding will also support annual GLC technical support visits to strengthen PMDT
capacity.
Above Allocation
The above-allocated funding request will be used to sensitize management in congregate
work settings e.g. mines, prison, factories on DR-TB and IPC, support laboratory
technologist training on 2nd line DST with the Ugandan WHO SNRL as well as the rollout
of the Laboratory Information System (LIS) and procurement of additional GIS mapping
devices to strengthen ongoing activities in electronic mapping of patients coordinates to
facilitate patient follow-up and monitoring. Equally as important is the continuation of
nutritional support and transport allowances to support continuation of treatment. The
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04Nov 2014│ 88
NFM funding will also support the development of guidelines on the “Providing Palliative
Care to Patients with DR-TB” in line with the ‘Declaration on Palliative Care and
MDR/XDR-TB’ launched in 2013. This includes training of health care workers on MDRTB palliative care. The Global Fund has been supporting the procurement of 50% of the
country’s need for second line anti-TB medicines. The NFM funding will support this
activity for the treatment of 50% of the estimated 3103 DR-TB patients throughout the 3year implementation period. Swazi government will secure the remaining need of 2nd line
drugs.
Health Systems Strengthening Module
Goals and objectives of the NFM funding request:
The main purpose of this funding request is to strengthen the four pillars of the health
system; namely HIMS, PSM, service delivery and health and community workforce.
HMIS
Rationale and impact
The rationale for prioritizing HMIS is to improve the capacity for generation of Reliable,
Integrated and comprehensive HMIS data that will assist in monitoring and evaluation as
well as decision making for MOH by:  Strengthening the coordination of health research
 Building surveillance systems
 Linking with vital statistics in coordination with the Ministry of Home Affairs.
Allocated Funding
The allocated amount will support the model of CMIS usage, Global Fund is being
requested to cover: 1) More networking and hardware/peripherals per site. 2) Cover the
additional 91 sites for LAN and 128 sites for WAN so that all 138 public health facilities are
fully connected/networked. The expected impact and outcome of this activity that targets
the entire population of Swaziland. The establishment of integrated data architecture to
coordinate and manage health information will greatly enhance the continuity in quality of
care for clients. Furthermore, the CMIS software development roadmap provides for
expansion into additional program areas: malaria, non-communicable diseases,
Above allocation
There is an above allocation amount requested is for technical assistants to ensure effective
implementation and oversight during project implementation for HMIS over the three
year period.
Procurement and Supply Chain
Rationale and impact
Procurement and Supply Chain was prioritised because it is a critical area for efficient
delivery of health care including HIV/TB and malaria products. In order for the global
fund grant to be effective it is necessary to improve the efficiency of the supply chain
management in the country.
The target population includes all patients accessing care through hospitals, clinics, public
health units and health centres. The impact of activities will ultimately lead towards
ensuring the right medicine in right quality and quantities at the right time at the right
place at right cost. The resultant effect will be a decrease in the barriers in access of
medicines for patients in need and reduction of stock outs and expiries. Other impacts of
the requested support also include efficiency gains from an integrated supply chain
Swaziland TB and HIV Concept Note
04Nov 2014│ 89
currently consisting three separate supply chains (medicines, ARV and laboratory).
Within Allocation
Under this component, the prioritised activities are capacity building, on procumbent and
supply chain management, bar coding, LMIS implementation and replacement of box vans
to reduce stock outs, expiries in facilities and pilferage. This is a priority to increasing
access to medicines. QC testing, ISO certification and shelving are prioritised in order to
improve the quality of medicines by testing and storing them in required environment.
Service Delivery
Rationale and impact
Rationale for selection and prioritization of the service delivery module is to increase
access to health services towards universal health coverage for HIV/TB, malarial and other
disease areas. The target population is the entire population of Swaziland. The service
delivery component has prioritized the upscale of health services to primary level facilities
by providing refurbishments and renovations for infection prevention control as well as
equipping these facilities with the essential equipment to provide health services as
indicated in the EHCP. The primary level facilities have been prioritized because they are
the entry level for patients especially those in rural areas.
Within Allocation
The provision of integrated services will assist in providing quicker access to other health
services to PLHIV as well as people on TB treatment. This will improve early health
seeking behaviour for people living with HIV and manifest opportunistic infections. This
will also have a positive impact on people with co-infections such as HIV -NCD or TB –
NCD before they develop complications. The refurbishment will have high impact by
minimizing possible infection for both patients and healthcare workers at facilities
especially high volume facilities. The impact will result in reduced exposure to TB infection
in health facilities because of implementation the infection control approved designs.
Above Allocation
The above allocation amount is to assist in increasing the number of facilities that upscale
their services thus increasing access to services.
Health and Community Workforce
Rationale
Health and Community Workforce was prioritized due to the fact that the continuing
shortage of health workers is the country’s greatest obstacle to reducing the burden of
disease especially across HIV/TB, as well achieving the targets defined in the country’s
Primary Health Care strategy. As a result, the focus has been on ensuring the MOH is well
positioned to develop and retain positions critical to the delivery of quality health services.
Within Allocation
Due to a shortage of health workers in Swaziland, a concerted effort by all stakeholders is
crucial to finding answers for scaling up the health workforce to ensure an adequate and
appropriately distributed workforce. As the government of Swaziland focuses on initiatives
to develop the health workforce and address the staffing gap, assistance from partners is
needed to optimize the existing health workforce through improving the quality and
relevance of the current health workers. As such, the Global Fund request has focused on
activities orientate and train the existing health workforce, especially in regards to the
skills required to provide essential services necessary to address the current epidemics of
HIV/AIDS, TB as well as Malaria. It is expected that this will result in improved
availability of qualified health workers to provide health services, improved health worker
productivity as well as improved job satisfaction and work climate and a reduction in staff
migration and turn-over
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Above Allocation
The above allocation activities focus on ensuring that the key line ministries are well
orientated on the social determinants of health with emphasis on HIV/AIDS, TB, Malaria
and NCDs to ensure that the government of Swaziland can mount a unified response
through leveraging activities conducted through the education, agriculture and other
relevant key sectors. Additionally, the above allocation funding also seeks to ensure
adequate specialized nurses to relive the burden on health workers in key area such as
PMTCT as well as ensuring an increased focus on the provision of primary healthcare
Community Systems Strengthening Module
Goal, objectives of the funding request
The goal of the planned modular interventions is to establish mechanisms for delivery of
integrated and coordinated community services.
The main objectives are;
(i) to strengthen community systems and enable them to lead and sustain
decentralized TB, HIV and Malaria response for improved access of the services
(ii) to strengthen integration of community services and link them to healthcare
system
Rationale for selection and prioritization of modules
Swaziland has adapted different community structures with involvement of a number of
actors ranging from CBOs, NGOs, faith-based organisations to community groups and
volunteers. Notwithstanding the invaluable contribution made over the last several years
in delivery of essential prevention, treatment and care and support services, there remain
gaps in coordination and integration of services, including linkages to the health system.
Expected impact and outcomes of modular interventions being proposed
1) Community based monitoring for accountability
The modular implementation is expected to map actors and harmonize the service delivery
with clear linkages within the community system and the health system. Monitoring of
service performance and financial accountability is expected to promote community
participation, improve access and efficiency of services.
2) Social mobilization, building community linkages, collaboration and coordination.
The implementation of this module is further expected to provide a road map for
community service delivery to enhance coordination, communication and standardized
quality of service provision. The action is expected to increase integration of TB, HIV and
Malaria services at community level. The involvement of the PLHIV, community health
workers and vulnerable population groups in livelihood programs will further empower
and retain the community health workers and ensure sustained service delivery.
3) Institutional capacity building planning and leadership development in the community
sector
Implementation capacity of CBOs, NGOs and community health workers has remained
weak and threatened by the dwindling resources. Capacity building initiatives in this
module will address skills gaps in the governance of these institutions and also strengthen
their ability to manage grants, monitor and report and account on the service delivery.
C) There is a total of $1,905,346 above allocation. This funding includes interventions to
support PLHIV, CHWs and vulnerable populations to build sustainable livelihoods
through engagement in income generating activities.
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3.4 Focus on Key Populations and/or Highest Impact Interventions
This question is not applicable for Low Income Countries.
For TB and HIV, describe whether the focus of the funding request meets the Global Fund’s
Eligibility and Counterpart Financing Policy requirements as listed below:
a. If the applicant is a lower-middle income country, describe how the funding request
focuses at least 50% of the budget on underserved and most-at-risk populations
and/or highest-impact interventions.
b. If the applicant is an upper-middle income country, describe how the funding
request focuses 100% of the budget on underserved and most-at-risk populations
and/or highest-impact interventions.
The World Bank classifies Swaziland as a lower-middle income country. The country has
identified key populations which include underserved and difficult to reach groups. Key
among these are mobile populations (migrant workers, miners, transport operators),
underserved populations (young girls and women, inmates, MSM, IDU), and those to
whom there were programs but there are still gaps (sex workers, in-school youth). The GF
request intervention areas are primarily targeted to these population groups, especially
those in the prevention module (customized interventions for key populations including
HCT, condom promotion, social and behaviour change, economic empowerment, etc.).
Likewise, activities under PMTCT serve women and children who both are among the
vulnerable population groups.
The TB program component also addresses gaps that affect key population most, including
TB-HIV co-morbidity, defaulting, and serves as a stepping-stone to maximize services to
children, prisoners, miners and women groups who are often marginalized sections of a
society. The identified strategic actions also address an emerging public challengepreventing and early management of drug resistance TB. As such, TB largely remains a
disease which disproportionately affects those with malnutrition, low socioeconomic
status, and the immune-compromised-which all are prevalent among those at the fringe of
society: the poor, children and inmates.
The health systems strengthening module primarily aims to improve quality and expand
access to essential services in benefits underserved populations. The community systems
strengthening further compliment the health system, through bringing much needed
services to the community-level. In a country with lower middle income, with high
prevalence of the three GF supported diseases, further compounded by gender disparities,
the investment remains critical to bridge gaps in access to both the TB, HIV, Malaria, and
other basic services.
Furthermore, the strategic interventions identified are those with high impact not only in
responding to the three program areas; but also adds value to institutional capacity
strengthening-an indispensable investment for the national health system. The emphasis
on integration of services and maximizing use of resources through joint planning and
excitation of common functions-such as training, logistics, and program review and
planning-in the long term saves resources and promotes an integrated approach to
healthcare.
Overall, the planned activities and proportion of the requested funds that benefit key
populations are more than 50%; taking into account the fact that these groups constitute
the majority of a developing nation-like Swaziland. The returns from the GF investment
and that of the other stakeholders support the national effort not only to address the three
target programs-but contribute to establish a robust health system capable of addressing
current and emerging public health challenges.
Swaziland TB and HIV Concept Note
04Nov 2014│ 92
SECTION 4: IMPLEMENTATION ARRANGEMENTSAND RISK ASSESSMENT
This section requests information regarding the proposed implementation arrangements
for this funding request. Defining the implementation arrangements for the program
including the nominated Principle Recipients (PRs) and other key implementers is
essential to ensure the success of the programs and service delivery. For the concept note
for TB and HIV, the Country Coordinating Mechanism (CCM) can nominate one or more
PRs, as appropriate given the country context.
4.1 Overview of Implementation Arrangements
For TB and HIV (including HSS if relevant), provide an overview of the proposed
implementation arrangements for the funding request. In the response, describe:
a. If applicable, the reason why the proposed implementation arrangement does not
reflect a dual-track financing arrangement (i.e. both government and nongovernment sector PRs).
b. If more than one PR is nominated, how co-ordination will occur between PR(s) for
the same disease and across the two diseases and cross-cutting HSS as relevant.
c. The type of sub-recipient management arrangements likely to be put into place and
whether sub-recipient(s) have been identified.
d. How coordination will occur between each nominated PR and its respective subrecipient(s).
e. How representatives of women’s organisations, people living with the two diseases
and other key populations will actively participate in the implementation of this
funding request.
The proposed implementation entails a dual track financing arrangement of government
and Civil Society PRs; NERCHA and CANGO respectively. The two PRs will work together
such that PR1: NERCHA will service all government SRs; while PR 2: CANGO will focus
on non-state SRs. Based on the SR selection criteria approved by the CCM.
Summary of Implementation Arrangements for Civil Society PR
Regarding the Civil Society SRs, no SR has been selected. What is planned is that selection
criteria will be prepared and be presented to the CCM for review and endorsement. The
PR will then use the criteria to identify the SRs. Worth noting is that CSOs under the
Swaziland HIV and AIDS Consortium SHACO prepared a CSO Charter where key
activities were identified based on CSO comparative advantage. The CSOs indicated areas
in which they are willing to participate and implement. Also, there are SRs that are
specialised and are anticipated to play a key role for key populations and this includes
SWANNEPHA (PLHIV), SWAMIWA (TB), Rock of Hope and House of our Pride
(SLGBTS). The information will then be shared with the Global Fund regarding the details
of SRs and the activities they have been allocated to implement. The activities will be as
follow:







Monitoring for accountability
Social Mobilization
Building community linkages
Collaboration
Coordination
Institutional Capacity Building
Prevention- mother to Child transmission
Summary of Implementation Arrangements for Government PR
Swaziland TB and HIV Concept Note
04Nov 2014│ 93
The implementing entities for this PR will involve government departments, especially
within the Ministry of Health, and these will included:







National Tuberculosis Control Program
Maternal and Child Health
Central Laboratory Services
Central Medical Stores
Swaziland National AIDS Program / SNAP
Strategic Information Department
Health Facilities including Mission Hospitals
In terms of reporting channels, the SRs will be responsible to prepare reports in
accordance with reporting templates, the reports will be forwarded to the PRs who will
synthesise and prepare a consolidated performance report. The consolidated report will be
then presented to the CCM oversight committee and the final report will be reviewed and
endorsed by the full CCM.







Monitoring for accountability
Social Mobilization
Building community linkages
Collaboration
Coordination
Institutional Capacity Building
Prevention- mother to Child transmission
To mitigate the problem of stock-outs, the two PRs will work closely with the TB and HIV
Programs and SRs to ensure requisitions are implemented in a timely manner; such that
orders are placed three months in advance before the expected activity or delivery of
commodity, using its requisition tracking system.
The two PRs will be holding quarterly meetings to share progress to date and
implementation bottlenecks.PR1, NERCHA being national coordination body for the
multi-sectoral response will be responsible for consolidation of programmatic and M&E
reports. But both PRs will both make presentation to CCM Oversight Committee.
The two PRs will have monthly coordinating, monitoring and mentoring meetings with
their sub-recipients gradually moving into quarterly depending on the SR capacities.
SWANNEPHA, SWAMIWA, Rock of Hope and House of Our Pride, SWAGAA etc. already
have interface with both PRs and programs. Regular dialogues and consultations by both
PRs in their coordination meetings will include these key stakeholder organisations during
grant implementation.
4.2 Ensuring Implementation Efficiencies
Complete this question only if the CCM is overseeing other Global Fund
grants.
From a program management perspective, describe how the funding requested links to
any existing Global Fund grants, or other funding requests being submitted by the CCM at
a different time. In particular, explain how this request complements (and does not
duplicate) any human resources, training, monitoring and evaluation, and supervision
activities.
Continuation of critical TB control activities funded under the current grant and the nocost extension plan has been prioritized in the NFM. These activities will allow the NTCP
Swaziland TB and HIV Concept Note
04Nov 2014│ 94
to increase its case detection and diagnosis rate as well as the linkage of diagnosed TB
patients onto TB therapy. Some donor-funded positions (9) are pending absorption into
the government establishment and therefore critical HR salary support will be requested
from GF in the NFM for continuum of quality care.
This funding request complements the current TFM (HIV) and TB grants expiring in
December 2015 and March 2015 respectively. There is no duplication of human resources,
training, monitoring and evaluation and supervision activities, as the forecasted budget
allows for the necessary activities implemented by the current human resources to be
implemented in accordance with the current malaria season. This allows for the timely
implementation of the eNSF and TB National Strategies which end 2018 and 2019
respectively.
Under the NFM, both programs will ensure that critical cross-cutting interventions for the
health sector overall add value from synergies derived from the integrated approach
minimizing or eliminating inefficiencies in human resources, training, M&E, and
supervision activities.
4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery
For both TB and HIV complete the table below for each nominated PR. For
more information on Minimum Standards refer to the Concept Note
Instructions.
National
Emergency
Response
PR 1 Name
Council
on
HIV and AIDS
(NERCHA)
Does this PR currently manage a
Global Fund grant(s) for this
disease component or a standalone cross-cutting HSS grant(s)?
Minimum Standards
1. The
Principal
Recipient
demonstrates
effective
management structures and
planning
Sector
X Yes
☐No
CCM assessment
NERCHA is a corporate body and has set structures
recommended for good governance. The body of
NERCHA (referred to by the NERCHA Act as the
Council) is the board and is made up of 15 nonexecutives plus the National Executive Director of
NERCHA. The members of the Council consist of
individuals from the government, Private Sector,
Civil Society, Law Society, Accounting Environment,
Dental and Medical Council, Traditional Sector and
Parliament.
NERCHA has been a Principal Recipient for Global
Fund grants for AIDS, Tuberculosis and Malaria
since 2003. The profile of the grants managed,
excluding the Transitional Funding Mechanism for
AIDS, is as follows:
Round
Swaziland TB and HIV Concept Note
GOV
Disease
Component
Overall
Performance
04Nov 2014│ 95
2
HIV/AIDS
B2
2
Malaria
B1
3
Tuberculosis
A1
4
HIV/AIDS
B1
8
Tuberculosis
B1
7
HIV/AIDS
B1
8
Malaria
B1
8
HSS
A2
10
Tuberculosis
B1
There is a Grants Management Unit which has been
managing grants since 2011. OIG audited the grants
and made recommendations which have since been
complied with.
The organizational structure of NERCHA is divided
into two sections, Coordination which leads the core
business, and the Technical Department which is a
support function. The Technical Department
consists of the Finance Unit, Procurement Unit and
Grants Management Unit.
2. The Principal Recipient has the
capacity and systems for
effective
management
and
oversight of Sub-Recipients
(and
relevant
Sub-SubRecipients)
During the implementation of Global Fund Round 7
phase 1 and 2, NERCHA developed systems for
undertaking sub-recipient capacity assessment in
the areas of financial, procurement, monitoring and
programmatic management. In addition to assessing
SRs, NERCHA has also included the sub-recipient
assessment criteria in its Grant Management
Manual. To develop the capacity of the SRs,
NERCHA has established within its organizational
structure an Organizational Development Unit
which focuses on developing the capacity of Civil
Society Organisations (CSO) predominantly working
in the area of HIV/ AIDS, irrespective of whether
they are recipients or non-recipients of Global Fund
Grants. The grants rating indicated earlier
demonstrates the high capacity in SR management
and oversight.
3. The internal control system of
the Principal Recipient is
effective to prevent and detect
misuse or fraud
NERCHA has over the years developed various
internal control policies for governing its business
and continues to review and strengthen these
policies as new developments emerge. The policies
included
Human
Resources
Management,
Procurement and Tendering, Finance and
Accounting Manual which include fixed asset
management, Grants Management Manual, Training
policies for its staff, Standard Operating Procedures
for Trainings funded by donors and Vehicle
guidelines for NERCHA’s.
Swaziland TB and HIV Concept Note
04Nov 2014│ 96
Some of these policies have been reviewed and
strengthened
following
the
audit
inspection/verification carried out by the Global
Fund through the Office of the Inspector General
(OIG) in 2010.
In 2013, through Global Fund support, a department
for internal audit was established. The Finance and
Audit Committee meets quarterly to review reports
submitted by the internal audit department to
ensure financial oversight.
NERCHA has undergone annual audits, none of
which has been qualified and none of which detected
any case misuse or fraud. Continuous assets
verification exercises are done with SRs to ensure no
property or vehicles are misused.
4. The financial management
system
of
the
Principal
Recipient is effective and
accurate
NERCHA has had the privilege of managing Global
Fund and other donor resources for more than 10
years and over the years has developed various
internal financial control systems and financial
management systems. NERCHA has always
maintained a robust accounting system for the
recording of grant expenditures for expenditures
incurred by all implementers.
In 2013 the Global Fund, in an effort to assist with
financial management systems, appointed and
placed with NERCHA a Fiscal Agent. The Fiscal
Agent has reviewed NERCHA’s manuals and
Accounting systems, installed and trained staff on
the new accounting systems. This has facilitated
effective and accurate financial management
systems.
5. Central
warehousing
and
regional
warehouse
have
capacity, and are aligned with
good storage practices to ensure
adequate condition, integrity
and security of health products
To be consistent with the Global Fund principles of
strengthening national systems, NERCHA uses the
national supply chain management system for the
storage and distribution of health products.
NERCHA, through Global Fund’s support, has also
ensured that investments are made to the national
supply chain management systems. NERCHA is also
a part of the Supply Chain Management Technical
Working Group charged with the responsibility of
making sure that there are no stock-outs of health
products, and that effective storage and distribution
systems are in place.
6. The distribution systems and
transportation
arrangements
are
efficient
to
ensure
continued and secured supply
of health products to end users
to avoid treatment / program
disruptions
The procurement system of NERCHA is robust and
complies with the procurement requirements of the
Global Fund in all respects. This was developed
through the assistance of Deloitte-USA through a
private partnership arrangement by the Global
Fund. To further enhance the capacity within the
procurement unit at NERCHA, a Procurement
Specialist was engaged to train staff and the
NERCHA Tender Board on the Procurement
Swaziland TB and HIV Concept Note
04Nov 2014│ 97
Manual. To mitigate stock outs of ARVs NERCHA
has, through its own resources, placed a Senior
Supply Chain Pharmacist at the ARV Warehouse
under Central Medical Stores. NERCHA is currently
co-financing with the Global Fund the rental of an
additional warehouse for Central Medical where
ARVs and other medical products are stored.
The Global Fund is currently funding, through the
SSF grant, a Technical Advisor to assist the Assistant
Director responsible for warehousing and logistics
develop a comprehensive supply chain improvement
plan for the country.
7. Data-collection capacity and
tools are in place to monitor
program performance
8. A functional routine reporting
system
with
reasonable
coverage is in place to report
program performance timely
and accurately
The PR function of NERCHA is embedded in a
system that has oversight over the multi-sectorial
national response on AIDS as well as other diseases.
In this respect, NERCHA oversees the national
Monitoring and Evaluation System and has
developed data collection systems that feed into
other M&E systems. This information is collected by
regions and after verification is recorded in the
Quarterly Service Coverage Report.
National reporting systems include the Health
Management
Information
System
(HMIS),
Swaziland
HIV/AIDS
Monitoring
system
(SHAMOS) and Immediate Disease Notification
System (IDNS). HMIS review has gave birth to the
national Unique Personal Identifier which is meant
to ensure real time client data.
NERCHA is linked to HMIS and SHAMOS, this
ensures easy reporting on Global Fund grants.
9. Implementers have capacity to
comply
with
quality
requirements and to monitor
product quality throughout the
in-country supply chain
The Ministry of Health, through assistance from
Global Fund and other partners, has acquired
quality control equipment. What still remains is the
laboratory and reagents; including critical human
resources to ensure quality control within the supply
chain management. Some of the gaps above have
been included in the HSS grant while programmatic
quality checks are made through routine technical
support visits by both PR and programs.
4.3 Minimum Standards for Principal Recipients and Program Delivery
Complete this table for each nominated Principal Recipient. For more
information on minimum standards, please refer to the concept note
instructions.
Coordinating
Assembly of NonPR
2
governmental
Name
Organisations
[CANGO]
Does this Principal Recipient
currently manage a Global
Swaziland TB and HIV Concept Note
Civil Society
[NGOs]
Sector
Yes
X No
04Nov 2014│ 98
Fund grant(s) for this disease
component or a cross-cutting
health system strengthening
grant(s)?
Minimum Standards
1. The Principal Recipient
demonstrates effective
management structures
and planning
CCM assessment
CANGO has managed Global Fund round 7 phase 2
through
NERCHA
and
currently
manages
PEPFAR/USAID grants through Pact Swaziland.
CANGO set up a Grants Management Unit [GMU] in
2011 which receives and disburses grants. This unit has
four [4] departments namely; Grants and Finance;
Organizational Development [OD]; Programs and
Technical; and Monitoring, Evaluation and Reporting
[MER].
The GMU has provided strategic information, technical
assistance and managed 11 sub-recipients.
Tools and systems in place include: organisational
capacity assessment tools, training materials, grant
manual, program planning documents, data quality
management systems, sites visit documentation, data
verification procedures and reporting guidelines.
2. The Principal Recipient has
the capacity and systems for
effective management and
oversight of sub-recipients
(and relevant sub-subrecipients)
Sub Recipient Management
CANGO has gained experience in managing HIV/AIDS
and TB programs through its GMU unit where 8
partners were supported through the PEPFAR USAID
grant implementing Prevention, OVC impact
Mitigation, HTC, TB/HIV and Gender Mainstreaming
and 4 Sub Recipients under Global Fund Round 7
phase 2. 1 received both the GF and USAID Grants.
CANGO has built the capacity of SR’s to ensure they
have adequate staff in all departments but especially in
M&E, Grants and Finance and Programs. Staff
orientation is conducted to outline roles and
responsibilities using an orientation guide.
CANGO conducts baseline assessments to determine
the capacity gaps of SRs. Capacity assessment tools
[CAT] such as management capacity assessment tool
[MCAT], Organizational Development Capacity
Assessment tool [OD-OCAT], Monitoring, Evaluation
and Reporting capacity assessment tool [MER-OCAT],
Programs and Technical capacity assessment tool [PTOCAT] are used.
CANGO provides technical assistance to SRs’ through
group-based trainings and one on one mentoring. In
the past 2 financial years (from 01 October 2012 to 31
Swaziland TB and HIV Concept Note
04Nov 2014│ 99
March 2014), CANGO has conducted a total of 289 site
visits to SRs.
Department
3. The internal control system
of the Principal Recipient is
effective to prevent and
detect misuse or fraud
4. The financial management
system of the Principal
Recipient is effective and
accurate
Swaziland TB and HIV Concept Note
Number of Site Visits
MER
96
Grants and Finance
59
Programs and Technical
90
Organizational Development
44
CANGO Internal Financial Control Systems
CANGO has financial management policies in place
such as the Finance/Accounting Policy; Procurement
Policy; Conflict of Interest; Anti-Corruption Manual;
and Grants Manual. These policies minimize the risk of
mismanagement of funds and foster compliance to
both organizational and donor requirements. CANGO
also conducts monthly management meetings in which
financial reports are reviewed. The financial reports are
also reviewed by the CANGO board.
Preparation of Financial Statements
CANGO has had unqualified annual audit reports since
2000 which have indicated low risk.
Donor Assets
CANGO has an asset register in place for all assets and
is monitored regularly. There are policies in place to
safeguard CANGO’s assets and these include the Motor
Vehicle usage Policy and ICT Policy. Disciplinary
actions are taken to employees not adhering to the
policies.
CANGO Financial Systems
CANGO uses the latest version of Pastel which ensures
security of data, segregation of duties through level
authorisation , it produces system income and
expenditure statements, trial balance and balance
sheets. Reports are produced for separately for each
donor.
Disbursements to SR’s
CANGO conducts Management Capacity Assessments
before signing grant agreement with SR’s. High-risk
SR’s are funded indirectly through an in-kind grants
and low risk SR’s are funded directly through a cost
reimbursement grant. An in-kind grant is whereby
CANGO pays suppliers and service providers directly
on behalf of the SR’s whilst assisting the SR’s to
strengthen their financial systems so that they can
receive funds directly from CANGO. A cost reimbursement grant is whereby funds are transferred to
SR bank accounts on a monthly basis.
On signing of the grant agreement, CANGO does not
04Nov 2014│ 100
5. Central warehousing
and regional warehouse
have capacity, and are
aligned with good
storage practices to
ensure adequate
condition, integrity and
security of health
products
6. The distribution
systems and
transportation
arrangements are
efficient to ensure
continued and secured
supply of health
products to end users to
avoid
treatment/program
disruptions
7. Data-collection capacity and
tools are in place to monitor
program performance
obligate the total allocated amount to the SRs but
obligates initially amounts for two months thereafter
monthly. An Obligation Matrix is used to document
obligations to SR’s and monitor burn rates. This helps
CANGO in ensuring pipeline tracking and statutory
obligation compliance.
Financial reporting templates are provided by CANGO
to the SR’s adapted from the donor reporting
requirements.
A financial report checklist is used to ensure that all
Global Fund requirements are met
Currently, CANGO has not been procuring, storing and
distributing health products; however SRs that CANGO
supports have been procuring health products through
the government Central Medical Stores. If CANGO is
required to procure, existing country structures will be
used. The health products will be distributed in
accordance with the Ministry of Health guidelines and
donor requirements and supply chain management
policies.
As alluded above, CANGO has not been involved in the
distribution and transportation of commodities. As a
new PR, CANGO will work with the national
mechanism to ensure an effective distribution system.
Since CANGO has good relations with the current PR,
if there is a need to distribute and transport
commodities , guidance will be sought from the
current, but our focus remains on integrating PSCM
into the national system.
The MER department has two skilled and competent
staff members: one MER manager and an M & E
Officer. The organisation has documented its MER
process through MER plans for the GMU and an M&E
Framework for the organisation.
SRs are expected to report to CANGO on a quarterly
basis on the progress of the programmes. CANGO
develops reporting templates with reporting guidelines
for SRs and conducts periodic reviews. The templates
feed data into the national M & E framework but
customized to suit the reporting needs of each funding
partner. A report review checklist is used to assess the
quality- timeliness and accuracy of the reports.
Reporting meetings are conducted periodically with
partners to address common reporting challenges and
review the reporting guidelines. Password protected
data aggregation tools are used to consolidate SR data
in order to produce reports. Data backups are
periodically conducted.
Swaziland TB and HIV Concept Note
04Nov 2014│ 101
CANGO assists SRs to conduct surveys and evaluations
to measure the impact of the projects, tools are in place
for such.
8. A functional routine
reporting system with
reasonable coverage is in
place to report program
performance timely and
accurately
9. Implementers have capacity
to comply with quality
requirements and to
monitor product quality
throughout the in-country
supply chain
CANGO has a Data Quality Management Plan which
establishes the guidelines that govern data quality. The
plan outlines the procedures that should be used to
ensure that data collection, collation, analysis, data
recording, storage, management, reporting and
dissemination are of high quality. Bi-annually data
quality assessments are done in order to evaluate and
verify the accuracy of results of SR programme
activities.
Through the CSS component social monitoring for
accountability, community score cards will help assess
product and service delivery quality. Awareness rising
on issues such patient charters, human rights and
gender equality and equity and barriers to access to
services will also monitor service delivery. The above
will ensure monitoring of drug stock-outs, drug
reactions and human rights violations.
4.4 Current or Anticipated Risks to Program Delivery and PR(s) Performance
a. With reference to the portfolio analysis, describe any major risks in the country and
implementation environment that might negatively affect the performance of the
proposed interventions including external risks, PR(s)and key implementers’ capacity,
past and current performance issues.
b. Describe the proposed risk mitigation measures(including technical assistance)
included in the funding request.
Swaziland faces external risks (i.e. political and economic) that may negatively affect
performance on the proposed interventions towards the goal arresting TB and HIV
prevalence.
Domestic financing does depend on economic growth; which is highly dependent on
fluctuations to the agricultural sector and trade with South Africa. An economic downturn
may compromise government cash flows, which are necessary for everything from timely
procurement of drugs to fuel for all vehicles, even those purchased by a donor.
Risks Associated with the Principal Recipient and Mitigation Measures
Programmatic Risk:
i.
ii.
Limited public health expertise – Whilst this has not negatively impacted Grant
Management before, it limits both the PRs’ confidence in approving requisitions
presented by SRs and the data verification at facility-level, given that various data
elements may have to be considered in determining programmatic performance.
To mitigate this risk, the PRs will have regular program review meetings with the
identified SRs. Further, both PRs will deploy its personnel to periodically evaluate
performances on grant implementation.
Robustness of the MOH HMIS system – Though outside the authority of the PRs,
this does pose a risk to the performance management of the grant. The PRs will
have good access to the data collected by SRs.
Swaziland TB and HIV Concept Note
04Nov 2014│ 102
iii.
The PRs will jointly hold periodic meetings to improve the linkages, coordination
and oversight between the PRs, CMS; and TB and HIV programmes. A deliberate
effort will be made to enhance communication and information flow; including
streamlining roles and responsibilities between the various stakeholders.
To mitigate this risk, a clear delineation of roles and responsibilities between the
different parties will be established so that communication and information flow is
predictable and consistent, thereby avoiding issues in implementation particularly
regarding data collection, verification, and reporting.
Fiduciary & Financial Risks:
i.
Incurring of ineligible expenses – The PRs have systems in place enabling grant
management staff to track their budgets on a daily basis.
ii.
Low absorption of funds – This is not anticipated as a measure risk under the NFM
as GF is expected to sign ‘ready’ grants; and PRs anticipate that conditions
precedent, special conditions, and management letters will also be limited under
the NFM. This will be a positive to ensure that periodic plans are executed
according to the timelines agreed and that disbursements will flow.
iii.
Staff fatigue and turnover – This is a high risk for program implementation and
with the high turnover on the grants management for the programs; severely
compromising accurate and timely reporting.
To mitigate the above risk, the PRs have restructured their GMUs to enhance
effectiveness in terms of staffing and remuneration levels. This will ensure
competitive salary levels and staff retention.
iv.
v.
Late conclusion of procurement processes – Late conclusion of tenders has been a
problem and has stifled absorption and implementation of activities. This is mainly
due to the fact that the technical evaluation committees from different user
programs are comprised of members who have their full time jobs.
To mitigate this risk the PR , whilst it continues to investigate possibilities of
outsourcing this function, will ensure, in consultation with disease programs, that a
robust PSM plan with accurate timelines for delivery and signed off product
specifications are assembled prior to grant negotiations. This will allow tendering
for the whole plan and signing procurement contracts with suppliers very early into
implementation.
Grant Administration & Oversight Risks:
i.
To mitigate grant administration and oversight risks, the PRs will agree with
disease programs and the MOH overall, who are the largest implementers of GF to
set up proper GF governance arrangements. This will include determining forums
where PRs present programmatic and financial reports and structures through
which grant management issues could be escalated up to the Senior Executives of
MOH and Directors of Civil Society Organisations which are SRs. Further, the PRs
will, with assistance from partners, provide detail orientation of Global Fund
management requirements.
Other General Risks:
i.
Expectation Gap between PRs and IPs and or SRs – this is a risk where
Implementers do not have a full appreciation of the fiduciary responsibilities and
accountabilities of the PRs.
Swaziland TB and HIV Concept Note
04Nov 2014│ 103
A budget for this has been included in the budget work plan – it will be charged to
the proposed management fee.
ii.
iii.
iv.
Grant Management Risks beyond the capacity of the Ministry of Health and
organisations which are SRs. This relates to risks whose mitigation requires the
support of other government Ministries or and civil society organisations which are
SRs.
For instance, risks associated with supply chain management and absorption of
staff. These would often times require budget support from Ministry of Finance
and Ministry of Public Service for HR. This is a difficult risk to mitigate and the PR
had, in previous engagements with Global Fund missions, recommended that such
conditions should be escalated to the CCM Funding. This would help the PR to
focus on grant management issues over which it has the full authority to solve.
Remaining period of the Fiscal Agent - For government PR; NERCHA has just
installed, through the assistance of the Fiscal Agent a new Accounting system and
is undergoing a restructuring of its Grants Management Unit. For the PR 2,
CANGO – similar measures and systems would have to be put in place to mitigate
the risks.
Risks Associated with the Implementing Partners and Mitigation Measures
Programmatic Risks
i.
Limited capacity in laboratories; RDT false negatives found through secondary
testing with microscopy, without which may lead to the misdiagnosis and wrong
treatment of patient
ii.
Delayed forecasting, procurement, and delivery of TB – HIV commodities
Programmatic Risk-Mitigation Measures:
i.
The programs will work closely with stakeholders (i.e., CMS, government and
CSOs) and partners to ensure the appropriate quantification before procurement.
ii.
Data collection increasingly, in real-time by programs and at national level through
HMIS, both with support from the Global Fund, will allow for timely submissions
of the PUDRs.
iii.
The programs and SRs working closely with MOH M&E will ensure data quality by
designating a focal M&E officer, who is in constant contact with the programme
and the Strategic Information Department (SID).
The Health Promotion teams will work to ensure mass media messaging remains relevant
and effectively ensures population knowledge of TB and HIV. It will also target messaging
and interventions to groups that may remain at higher risk.
CORE TABLES, CCM ELIGIBILITY AND ENDORSEMENT OF THE CONCEPT NOTE
Before submitting the concept note, ensure that all the core tables, CCM eligibility and
endorsement of the concept note shown below have been filled in using the online grant
management platform or, in exceptional cases, attached to the application using the offline
templates provided. These documents can only be submitted by email if the applicant
receives Secretariat permission to do so.
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Table1: Financial Gap Analysis and Counterpart Financing Table
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Table2: Programmatic Gap Table(s)
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Table3: Modular Template
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Table4: List of Abbreviations and Attachments
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CCM Eligibility Requirements
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CCM Endorsement of Concept Note
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Sources:
Annexure 1. The extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018
Annexure 2. Swaziland National Tuberculosis Strategic Plan 2015-2019
Annexure 3. The Second National Health Sector Strategic Plan 2014-2018
Annexure 4. Swaziland National Operational Plan 2014-2017
Annexure 5 Swaziland Civil Society Priorities Charter 2013
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