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 shouldarticulate 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.
IMPORTANT NOTE: Applicants should refer to the TB and HIV Concept Note
Instructions
03 Oct 2014│ 1
to complete this template.
TB and HIV Concept Note Swaziland Draft III
SUMMARY INFORMATION
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.
TB and HIV Concept Note Swaziland Draft III
03 Oct 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
Shisewlweni. 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: 2011-2015).
HIV/AIDS
Swaziland has one of the highest HIV prevalence in the world with 26 per cent 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 epidemic was first confirmed in 1986 and its 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.
With regard to age, for example, in 2004 the prevalence among 15-19 year age group ANC
attendees was 32.5% while it was 45.4% for those in 20-24 years age group (Fig 1). Prevalence
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 3
rates by age also differ between men and women with peaks in 30 - 34 year olds for women
(54%) and 35 – 39 year olds age groups for men (47%) (SHMIS 2011).This is likely due to
early sexual debut and practice of inter-generational sex practiced among girls with older
men. In 2010, 2.7% women and 16% men reported having had more than one partners within
a year (MICS, 2010). In the same year, 70% of sex workers aged 15-49 years who reported
participating in paid sex were HIV positive (BSS MARPS 2010), and rate of women aged 1524 who had sex with men who are 10 or more years older than them has doubled from 7%
(2006/7) to 14% in 2010. The practice of intergenerational sex is mainly driven by the local
practice whereby young women are married away to older men or engage in sexual
relationships with older and richer men in exchange for financial and material support (MICS
2010).
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. HIV
disproportionately affects women, 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 among 20-24 years age groups
had the highest gender disparity with 7% for men and 31%; for women; however this
difference narrowed with older age.
Incidence is 2.38% in the age group 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 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 an 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 4
Source: SHIMS 2011
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-Annex xx).
The geographic hot-spots are mainly major urban centres, cross-border points, towns around
textile and sugar cane industries, and major transport and trade corridors. Key among this is
the southern transport corridor which runs between Mozambique and Swaziland through
locations that have amongst the highest HIV prevalence.
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 15-24 years with 22.9%, and MSM with 17.7% (GAP 2014).
The eNSF emphasizes on strengthening targeted interventions to most at risk population
groups including designing innovative approaches to reach the unreached with high-impact
interventions.
Critical barriers to HIV prevention and treatment include gender inequalities and GBV,
stigma and discrimination, low levels of male circumcision (only 19% for 15-49years in 2011)
and sero-discordancy. Gaps in comprehensive knowledge on HIV and lack of consistent and
correct condom use remain a challenge. This was evident from the finding that only 56% of
young people aged 15-24 both correctly identified ways of preventing sexual transmission of
HIV; and only 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. Despite
high prevalence of HIV infections (70.4%), condom use even among sex workers is not
universal. Recent data show that 86% of sex workers reported using a condom with their
most recent client. The status of condom use among MSM (HIV prevalence of 17.7%) is
unknown (GAP 2014). To address current information gaps, MOT study is justified as the last
one was done five years ago.
HIV Estimates and Projections show new infections among children at 18 months declined
from 19.6% in 2009 to 10.1% in 2012. However, it is important to note that Swaziland has
made progress in reducing mother-to-child transmission of HIV with only 3% of 11,469 HIVexposed infants testing HIV positive at 6-8 weeks of birth in 2013. Nevertheless, to ensure
elimination of MTC there is a need to further reduce transmission during breastfeeding,HIV
transmission rate among children remains high (10.1% at 18 months). This is largely
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 5
attributed to the long breast feeding period; delays in detection and starting prophylaxis,
interruption of treatment To address this, it is important tofurtherstrengthen 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). Generally viral load amongst males and
females living with HIV is similar as 68% of males and 64% of females have high viral loads
(i.e. >1000 copies/ml). 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 intensifying ongoing efforts to scale-up HCT, and enrolment
and retention to treatment programs.
Tuberculosis
Swaziland currently ranks first among countries with the highest tuberculosis (TB) incidence
in the world at 1,350 cases per 100,000 population (WHO 2013 Global Tuberculosis Control
Report).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. The
recognition of TB as a major public health challenge prompted high level political
commitment by declaring TB a national emergency in March 2011.
In 2013, Swaziland notified 6,665 TB cases of all forms (541 cases per 100,000 population).
However, an Epidemiological Analysis conducted during the WHO-led NTCP External
review in April 2014, revealed a declining trend in the TB case notification rate, below the
WHO modelled estimates. The total number of TB cases and notification rate increased
progressively from 2002 to reach a peak in 2010, following which the yearly number of TB
cases decreased successively with a mean percentage change of 16%. This decline was
concomitant with an important scale-up in the provision of antiretroviral treatment to
PLHIV with advanced disease (Fig 3).
Figure 3: TB case notification trends 1991 - 2013
Source: NTCP review report, 2014
MDR-TB is an emerging challenge to the country. A 2009 national representative drug
resistance survey (DRS) showed an MDR-TB prevalence of 7.7% (regional average: 3%)
among new TB cases, and 33.7% (regional average: 12-13%) among previously treated TB
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 6
patients. In 2010, between 7-10% of all new TB cases were multidrug-resistant (Swaziland
Drug Susceptibility Survey, 2010). Treatment outcomes trends are indicated below (Fig 3).
Contributing factors to sub-optimal treatment outcomes were: previous low treatment
success rate among DS-TB of 40-50%, delayed and incorrect bacteriological diagnosis among
new cases which led to case mismanagement and high empirical treatment initiation. This is
mostly a consequence of a highly centralised system currently undergoing extensive
decentralisation-which is already constrained by inadequate qualified health personnel and
weak lab diagnostic capacity.
Figure 1: MDR Treatment outcomes 2009, 2010 & 2011 cohorts
Source: NTCP
To address these gaps, the NTCP capacity was built for programmatic management,
systematic planning of training, and in QRM. TB services were decentralized to 8 sites with
plans for additional 5 sites by 2019, capacity for lab testing, forecasting and quantification of
TB drugs and supplies were strengthened. This was accompanied by an expansion in
community based DR-TB management, with the establishment of regional DR-TB clinical
teams, who provide supportive supervision to facility staff and outreach services to stable
patients. As a result of the above, there are improvements in the TB treatment success rate
which increased from 68% in 2009 to 76% in 2013, although still below the WHO target of
85%. However, there were differences within the different administrative regions (Fig 4).
Figure 4: Treatment outcomes for TB patients over time, 2008-2013
Source: NTCP
The country also faces 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 7
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 66% TB/HIV co-infected patients receiving treatment for
both in 2012, an improvement from 35% in 2010. Similarly, HTC uptake by TB patients has
increased from 86% in 2010 to 96% in 2013. At the end of 2013 a total of 3544 (75%) HIV/TB
co-infected patients were enrolled on ART (Table 1).
Table 1: TB/HIV and treatment coverage, Swaziland, 2010-2013
2010
2011
2012
2013
% tested for HIV
86
92
92
96
% HIV positive
82
77
80
74
% on CPT
93
96
98
99
% on ART
35
51
68
75
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. Children, healthcare workers, prison inmates, miners and
PLHIV are identified as more at risk of TB infection. Vulnerable groups at risk of HIV
infection include: sex 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 behaviors which limit their access to
services. Migrant workers may not also 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 care giver. 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 1712 registered Paediatric TB
cases, 79% (1361/1712) were tested for HIV test 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); HIV transmission rate among children remains high
(10.1% at 18 months). Girls and young women are at risk of HIV infection also due to child
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 8
marriage and polygamy whichare 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 percent 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 2400/100,000 pop. 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 6000 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 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 2315 healthcare workers screened for TB, 31%
had symptoms suggestive of TB; and 31% had a positive GeneXpert result, among whom 2
were rifampicin resistant. The incidence of TB was 997/100,000 population (An evaluation
of a pilot TB wellness screening project (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. While almost all sex workers live in cities and towns with better access to HIV
services, socioeconomic and cultural barriers may hinder optimal use. However, 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 9
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, services provided for the general public can also be accessed by the group.
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 on-going and results are expected by
end of 2014 to inform programming.
1.1
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 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 rightsapproach delivery to services.
Latest figures show that public attitudes to HIV and PLHIV are improving. 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 percent 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 10
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 HIV-related
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 5). While efforts have been made to ensure health equity through
decentralization of services, the high TB/HIV co-epidemic has placed a heavy burden on the
existing health system, compromising the quality and integration of service delivery. This
was evident from the Service Availability Mapping (SAM 2013) which reveals that out of the
287 health facilities, only 133 (46.3%) facilities provide ART services while less than a third87
(29.6%) offer integrated TB/HIV services. The government of Swaziland is decentralizing TB
services to more HIV service sites by infrastructure refurbishments with the infection
prevention and control project funded through World Bank. This is expected to integrate
TB/HIV services to community and health systems, including prevention, case detection, and
management; and improve information system for the three diseases.
Figure5 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
The ongoing effort to expand and integrate TB and HIV services at all level of the health
system is constrained by lack of adequate number and mix of health workforce. According to
WHO report, Swaziland is one of the 57 countries classified as having an HRH crisis. Whereas
WHO recommends a minimum staff-population ratio of 2.5 (doctors, nurses and midwives)
per 1000 people, the ratio for Swaziland is 1.69 per 1000 falling below the recommended
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 11
minimum (HRH Rapid Assessment, 2009). A staffing norms assessment report (2013),
revealed a gap of 40%, creating a significant challenge in personnel required to achieve
equitable access to quality TB and HIV services. The nursing cadre has the largest gap in
terms of absolute numbers (333 nurses representing a gap of 18%) between current filled
government-funded positions and the optimal health workforce. 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 (20122015) 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 faces health management information system (HMIS) constraints- rely heavily
on paper-based tools. The April 2013 HMIS Project Review report highlighted the
fragmentation, silo existence, and lack of interoperability of health information databases.
Similarly, the National Health Sector Strategic Plan (NHSSP) notes that there ispoor 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; compromising the move towards an
integrated HMIS. 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,
equipments 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 in the warehouses and limited capacity for
distribution of commodities due to weak transportation system.
Other challenges include lack of appropriate skills set required for the system, inventory
management not rolled out to facilities including in compilation and analysis of data, lack of
functional Quality Assurance laboratory, and weak transportation system. To address these
constraints, the Ministry of Health has developed a Pharmaceutical Strategic Plan (20122016) 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). This
strategic plan is timely to cope with the roll-out plan for Option B+ which demands for
expeditious procurement, supply and distribution mechanism.
Health service delivery in Swaziland is guided by the National Health Sector Strategic Plan
(NHSSP) which emphasizes on equitable access to healthcare. While it is estimated that 85%
of the population lives within 8km radius of a health facility, the distribution in the country
ranges from 16.3/100,000 in Shiselweni to 25/100,000 population in Manzini (EHCP,
2010). However, it is important to note that more facilities have been established since this
estimate and the coverage is likely to improve further. To further facilitate this process, 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
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defines the services that need to be available for each level (national referral hospital, regional
hospitals, health centers, clinics and community), and informs the type of structure
equipment and human resources to be provided at each level. The EHCP prescribes that all
facilities including at 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 enroll 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, integration of different services including for 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).
The community health system is supported by a number of community actors including
traditional, the private, government and NGOs. The traditional systems (volunteers, CBOs,
FBOs) provide services such as demand creation, treatment adherence and support, and
follow-up defaulters, and health promotion on the three diseases. The private 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 communitylevel services through the services of rural health motivators who provide primary healthcare
services at household levels.
The community structures include Tinkhundla committees, Chief’s advisory committees
(bandlancane), community development committees, community HIV committees,
municipality coordinating committees, social services related committees, and community
volunteers. These groups work through the rural community and urban-based community
administrative systems-constituted of 55 Tinkhudlas and 320 chiefdoms in rural areas; and
40 wards within towns and cities provide oversight on the above in their respective levels.
The various systems mentioned above provide invaluable support and compliment the
functions of the health system. Nevertheless, there are no mechanisms that clearly define
linkages and synergy between the community systems and the health system. As a result, the
contribution of the community system is not incorporated into national M&E report.
To address the above gaps in linkages/integration between the health and community
systems, the Ministry of Health has developed a National referral tool and a referral and
linkages SOP to systematically link health facilities to community-level health service
delivery. There is also a move towards structuring the community system around the six
building blocks of the health service delivery system for a meaningful engagement and
participation of community actors in TB/HIV programs.
As highlighted in the above sections, the government has identified priority needs for
strengthening health and community systems, and developed strategies to address these.
However, while the government has intensified its efforts to implement the plans through
national budget and donors’ assistance, there is a need for GF funding to bridge gaps in the
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four strategic pillars: HMIS, PSM, service delivery, and health and community systems and
the workforce (refer to 3.2).
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
1.2.1. Goal, Objectives, Strategies (eNSF 2014 – 2018))
Following the Joint Mid-Term Review of the National Strategic Framework (NSF) for
HIV/AIDS (2009-2014), the Government of Swaziland decided to extend the NSF for a
further five-years from 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).
Goal of the eNSF
Halt the spread of HIV and reverse its impact on Swazi society
Objectives of the eNSF
i. 50% and 90% reduction of new HIV infections among adults and paediatrics,
respectively, by 2015.
ii. Avert 15% deaths amongst PLHIV and in particular those with TB/HIV co-infection.
iii. Alleviate the socio-economic impacts of HIV and AIDS among vulnerable groups and
across the population generally
iv. Improve efficiency and effectiveness of the national response
Priority Programmes and Strategies
i. HIV Testing and Counselling (HTC). The objective of the HTC programme is to
ensure that all children, women and men get tested and know their HIV status. The
following are the priority strategies:
 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)
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
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): The objective for the social and behaviour
change programme is to strengthen public awareness and comprehensive knowledge of
HIV risks and vulnerabilities in order to increase personal risk reduction and uptake of
prevention services. The following are the priority strategies:
 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.
iii. Condom Promotion and Distribution: The objective is to ensure correct and
consistent use of condoms by all sexually active people. The following are the priority
strategies:
• 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. Male Circumcision (MC): The objective of the MC programme is to increase the
uptake of voluntary medical male circumcision (VMMC) among all eligible males in
Swaziland. The following are the priority strategies:
•
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.
v.
Customized interventions for Key populations: Swaziland identifies women
and girls, the youth, sex workers, men who have sex with other men, prisoners and
mobile populations as key populations at higher risk of HIV infection. The objective of
the programme is to improve the availability, access and utilisation of HIV prevention
and treatment services by key populations at higher risk of HIV infections. The
following are the priority strategies:
•
Address policies and legal barriers that prevent provision of comprehensive HIV
services to key populations (SW, MSM and PWID) 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: In June 2013, Swaziland adopted the
new World Health Organisation’s HIV Treatment guidelines which recommend
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changing the eligibility threshold for ART from a CD4>350/mm3 to count of CD4
>500/mm3. The objective is to improve the quality of life of PLHIV through treatment
and strengthen treatment as prevention. The following are the priority strategies:
•
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: The objective of the TB/HIV co-infection programme is to
prevent TB deaths amongst PLHIV. The following are the priority strategies:
•
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):The objective
is to strengthen the capacity of OVC families to effectively provide comprehensive care
and support for OVC. The following are the priority strategies:
• 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.
• 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):The objective is to strengthen national efforts to
prevent and manage Gender Based Violence (GBV). The following are the priority
strategies:
• 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.
1.2.2. Implementation to-date, challenges and gaps
Recognizing the challenges posed by HIV and AIDS, the Government of Swaziland
responded by establishing the Swaziland National AIDS Program in 1987. In 1999, HIV
was declared a national disaster by His Majesty King Mswati III. Soon after, the National
Emergency Response Council on HIV and AIDS (NERCHA) was established.
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
implementation of the strategy (Joint MTR of the NSF (2009 -2014)). It is this MTR as
well as annual programme reports for 2013/14and that inform implementation to date in
this section.
i.
HIV testing and counselling(HTC) services expanded to 264 out of the 287
health facilities (92.1%) in the country compared to 147 facilities in 2008 (SAM,
2013). Provider initiated testing and counselling which was launched in 2009 has
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contributed to a sharp increase in people tested and counselled in the last 12
months from 16% in 2007 to 40% in 2010 (MICS, 2010), and as indicated above
this figure reached to a record 336,497 in 2013. Uptake of HTC has been higher in
women compared to men, with 47.3%women tested in 2010 compared to 31.3%
men. For young people aged 15 – 24, 59% girls were tested and counselled in the
last 12 months compared to 31.5% boys(MICS, 2010). Interestingly, the proportion
of number of positive tests has been in a down-ward trend for the last fewer years,
declining from 25.6% in 2009 to 9.7% in 2013 (Figure 6).
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 6: Trends in HIV testing and counseling, 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
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
aresult,2.7% women and 16% 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 age 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% 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
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condoms are distributed by 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, condoms 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 challenge for a sustaining the current
declining trend in the rate of new HIV infections. 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 other modes of
transmission (MOT) study as the last one was conducted five years ago.
The main challenges and gaps for condoms are:
•
Inadequate evidence to inform programming for sex workers, MSM, IDU, uniformed
services
•
Limited targeted HIV prevention services for key populations
•
Insufficient policies to guide development and delivery of appropriate 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 uptake with 38% 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 /183 (89%) of the 183 ANC facilities provide PMTCT services. As a result,
99% eligible women attending ANC 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 global target of 90%). Eligible
pregnant women receiving ART for their own health increased from 40% in 2009 to 72%
in 2013. On early infant diagnosis; 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 over the years, however, a slight decrease from 88% in 2010, to 78.5% was noted
in 2013 & corrective measures are underway to rectify the decrease. The proportion of HIVpositive DNA PCR tests decreased from 12% in 2011 to 3% at 6-8 weeks. In 2013, 10750
(95%) of HIV exposed infants received NVP prophylaxis for PMTCT.HIV infections among
children at 18 months of age are estimated to be 10.1% of all exposed children in 2013,
down from 19.6% in 2009.
Challenges and gaps:
 High maternal sero-conversion (3%) among pregnant women at labour and delivery
 High unmet need for family planning (13%) among women of reproductive age (MICS
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



2010) and higher in the HIV positive women (65%).
High infant sero-conversion post-8-weeks.
High maternal mortality rate estimated at 60% among HIV positive women which
contributes to the high maternal mortality rate of the country.
Inadequate use of early infant diagnosis (EID) post-8-weeks
Low follow up of the mother by pair
vii. Treatment & Care: All clients who test positive are referred to pre-ART care,
available in all 133 facilities that provide comprehensive HIV services. Of these 117 initiate
and refill; while 16 do only refills. ART enrolments have continued to grow over the years,
averaging over 15,300 initiations over the last 3 years as the number of ART sites increased,
also with introduction of task-shifting from doctor to nurse led ART initiation. Based on
CD4 < 350/mm3 criteria the coverage was 85% in 2013. However, using all PLHIV as a
denominator, the coverage is 49.9% and of all HIV positive children, 57% are currently on
ART. Retention in care in 2013 at 12 months was 86%. According to SHIMS, 85% of PLHIV
who reported to be on ART were virally suppressed.
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: TB and HIV services
have been decentralised at different levels, with 133 facilities providing comprehensive
HIV services and 85 facilities providing TB services. In some facilities, services have been
integrated providing a ‘one stop shop’ approach to improve adherence to both treatments.
This approach contributed to improve HIV testing among TB patients with 92% of all TB
patients tested for HIV in 2012 and 80% 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). As a result, 73% of TB patients received treatment
for HIV while provision of CTX among TB/HIV co-infected patients has been sustained at
between 95% and 98%. (National TB Programme Report, 2012).There is a 30% gap in ART
initiation within 8 weeks in TB patients especially in children due to limited capacity
amongst service providers to provide care to paediatrics. This results in low coverage of
ART (57%) in HIV positive children less than 5 years of age (GARP Report for Swaziland,
2014). Uptake of IPT is relatively low, with an estimated 9% of PLHIV having been
cumulatively put on IPT between 2012 – 2014.Through the establishment of the National
TB/HIV Coordinating Committee (TB/HIV NCC), there has been is improved
collaboration between the HIV and TB programmes, with joint planning on cross-cutting
strategic interventions. However, there is concerning client loss along the diagnosis to
treatment cascade for both TB and HIV.
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: The proportion of
OVC has grown from 31.1% in 2007 (DHS) to 45.1% in 2010 (MICS). With more than half
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of the country’s population being under 20 years (CSO), Swaziland has at least 229,000
OVC, with one in every fourth Swazi child having lost one or both parents. Sixty two
percent of OVCs have all their three material needs met compared to 80% of non-OVC
(DHS, 2007). Only 41% of OVCs 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: Gender-based violence remains prevalent, with one in
three girls 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 multisectoral national violence surveillance system is established with routine data collation on
incidences of violence and abuse that collects information from nine organisations,
including DSW, RSP, MoE, DPP and civil society organisations. Child-friendly corners are
established in 24 police stations and child-friendly 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 SWAGAA.
Challenges and gaps:
•
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.
1.2.3 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 intervention 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 existing health system, compromising
service delivery
•
According to WHO, Swaziland is one of the 57 countries classified as having an
HRH crisis. Whereas WHO recommends a minimum staff-population ratio of 2.5
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•
(doctors, nurses and midwives) per 1000 people, the ratio for Swaziland is 1.69:
1000 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.
1.2.4 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) To reduce morbidity, disability and mortality from diseases and social conditions
(ii) To enhance health system capacity and performance
(iii)To promote effective allocation and management of health and social welfare resources
(iv) 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 National Health Sector Strategic Plan (NHSSP I, 2009 – 2013)
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) Increasing the numbers of health and related services and interventions being provided
across the country (introduction of interventions as and where needed)
(ii) Increasing the coverage of populations using the different health and related services
and interventions (scale-up of intervention use), and
(iii) 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
‘90-90-90 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).
1.2.5 Country processes for reviewing and revising HIV strategic plan
The country has established mechanisms for reviewing and revising the national HIV
strategy. A Joint Mid-Term Review of the Extended National Strategic Framework (eNSF)
for HIV/AIDS (2014-2018), will be conducted. This is usually commissioned by the
NERCHA, and done through a multi stakeholder consultative process. The review will be
crucial to ensure that the strategy responds to the local epidemiological context while at
the same time aligning to new global thinking. Areas for improvement and lessons learnt
will be incorporated in the National Operational Plan.
The costed National Operational Plan (2014 – 2017) will act as the tool for joint annual
reviews which will be 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. These decentralised structures
are the Regional Multisectoral 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 development of both the eNSF and NOP, and their own
individual plans are aligned to these national documents.
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TWGs also hold 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.
Tuberculosis National Strategic Plan
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 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 systems, drug supply systems, and 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 85 BMUs
(Level 1 PHC) for TB and HIV treatment initiation.
1.2.1. Goal, objectives and priority areas
The Goal of the TB National Strategic Plan (TB NSP) 2015-2019 is to achieve a 35%
reduction of TB prevalence rate by 2019.
The main objectives are;
(i) To diagnose and enroll on treatment at least a total of 40,000 TB cases by 2019.
(ii) To provide treatment for all diagnosed TB cases and achieve at least 90% treatment
success rate by 2019.
(iii)To implement and expand country-wide collaborative TB/HIV activities and
management of co-morbidities by 2019.
(iv) 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.
(v) To strengthen the NTCP national TB response management capacity to effectively
coordinate and evaluate TB prevention, treatment and care interventions.
Priority program areas
(i) Increase early case detection and diagnosis.
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(ii) Improve linkage diagnosed TB patients to treatment and eliminate
“pretreatment defaulting” and transmission.
(iii)Strengthen Integrated TB/HIV care, treatment and prevention services.
(iv) Decrease the high incidence rate for MDR-TB and reduce mortality.
(v) Address the weak information system (M&E, surveillance and Vital registration
system
1.2.2. Implementation to date and outcomes
The outgoing TB NSP (2010-2014) was designed based on the Global Stop TB strategy. The
implementation to date for the main objectives (1 and 2) are presented below:
Strategic Objective 1: To pursue high quality country-wide DOTS expansion and
enhancement towards achieving 100% population coverage with TB diagnosis and
treatment by 2015.
Envisaged Key strategic results and implementation to date:
i.
100% DOTS coverage by chiefdoms by 2014 (80% coverage within 8km)
ii.
At least 95% of health facilities in the country initiating TB treatment by 2014
([37%] 85 of 223 health facilities)
iii.
85% treatment success rate by 2014 (76% treatment success rate)
iv.
Strengthened Programme supervision
v.
100% of laboratories participating in QA (all peripheral, regional and national
laboratories participate in QA for smear/FLD/LPA, no QA program yet for
GeneXpert)
Strategic Objective 2: To address TB/HIV, MDR/XDR-TB and TB in vulnerable
populations:
Envisaged Key strategic results and implementation to date:
i.
At least 95% of TB patients tested for HIV by 2014 (95% of TB patients are tested
for HIV)
ii.
At least 95% of registered TB/HIV patients on CPT by 2014 (99% of TB/HIV coinfected patients put on CPT)
iii.
At least 75% of TB/HIV patients on ART by 2014 (70% of TB/HIV co-infected
patients were enrolled on ART, and there is ongoing roll-out of IPT pilots for PLHIV
without active TB disease)
iv.
Established programmatic management of DR-TB according to WHO guidelines
(PMDT has been introduced using an ambulatory model that covers the whole
country; and a spacious purpose-built national TB Hospital with own audiometry
services and laboratory capacity for non-TB laboratory tests for patient screening
before and during treatment is fully operational)
v.
At least 50% treatment success rate for MDR-TB cases (58% MDR-TB treatment
success rate)
vi.
At least 90% of high-risk groups (PLHIV, DM patients, TB contacts, prisoners)
screened for TB
1.2.3. Limitations to implementation:



There is a challenge with inadequate Human Resource at NTRL and NTCP levels as
83% of staff are donor funded. The community outreach unit of the TB hospital is
grossly understaffed to sufficiently support the outreach sites
Declining case notification rates against WHO modelled estimates and increasing
levels of drug resistance among new cases.
Weak vital registration systems contribute to inaccurate data and difficulty in
quantifying TB related mortality.
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



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.
Weak M&E: Reporting and recording for TB screening in PMTCT and other HIV sites
need to be strengthened.
TB treatment is not available in all clinics providing ART and PMTCT services as a one
stop-shop even though these far outnumber TB treatment initiating sites. There is
evidence of loss of patients in the diagnostic pathway associated with cross referral
practices between facilities.
There is low coverage with confirmatory first line DST (FLD) for GeneXpert diagnosed
cases and Second-line DST (SLD) for confirmed MDR-TB cases as per national and
international recommendations. This has resulted in less than 50% of expected MDRTB cases being detected based on the 2009 DRS and a low treatment success rate.
Actions to address limitations:
 Collaboration with SNAP to develop integrated TB/HIV reporting and recording tools.
 Expansion of TB Treatment initiation sites to from 85 to 145 by 2019 including PMTCT
sites. 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 BMU decentralization process.
 A DRS is planned for 2015 to assess levels of drug-resistance in Swaziland
 The national diagnostic algorithm has been amended 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 BioSafety Level 3 (BSL3) and capacity building for
SLD is being conducted in collaboration with the SNRL in Uganda
 Community treatment supporters and adherence officers have been recruited to
enhance community-based TB management and support
 MDR-TB Doctors and nurses have been recruited and trained on MDR-TB
management to strengthen the community based MDR-TB management
 The Ministries of Health and Public Service have been engaged to develop a Strategy
to facilitate the absorption of donor-funded positions within the NTCP into
Government establishment.
 The MoH is facilitating the strengthening of the M&E and Vital Registration systems
including development of the Client Management Information System (CMIS).
 Studies are planned for 2015 to assess the levels of under-reporting of childhood TB
and identify gaps in case detection.
 The NTCP will also conduct a national TB Prevalence survey in 2015/2016.
 Countrywide expansion in intensified and active case finding will be implemented
during the incoming NSP to improve current case notification.
Objectives 3, 4, 5 and 6:
The activities within these objectives have been implemented with minimal limitations
which have been addressed in the development of the incoming NSP (2015-2019) in
preparation for scale-up.
TB/HIV collaboration
The NTCP and SNAP have established a collaborative mechanism referred to as the
National Coordination Committee (NCC) to guide the successful implementation of the
WHO recommended framework for collaborative TB/HIV activities. The NTCP and SNAP
aims at strengthening the implementation of TB/HIV collaborative activities in line with
the WHO-led external program review of April 2014. Currently HTC, CPT and ART is
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provided to all TB patients as an intervention aimed at reducing the burden of HIV in TB
patients. The SNAP has rolled out systematic TB screening, infection prevention and
control (IPC), as well as the implementation of Isonized Preventative therapy (IPT) to
PLHIV. The NTCP will continue to closely collaborate with NGOs, CBOs, FBOs and other
organizations that provide home-based care services, which will in turn contribute to
expanding community-based TB care.
1.2.4. Linkages to national health strategy
The decentralization of TB services to primary health clinics supports the implementation
of the National Health Sector Strategic Plan (NHSSP I and II) in line with the Swaziland
Government decentralization policy. As such the main objective 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
1.2.5. Development process
The development of the TB 2015-2019 NSP was guided by the annual workshop on
National Strategic planning for Tuberculosis Control held in Cepina, Italy in November
2013. Following which a national strategic plan working group was formed to guide the
development process of the NSP. In March –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
stake holders (i.e. NCC) and partners for their inputs to ensure engagement of all relevant
parties for successful implementation of the NSP.
1.3 Joint planning and alignment of TB and HIV Strategies, Policies and
Interventions
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.
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Overview: Although the NTCP and SNAP function as vertical public health programs,
there is oversight by the National TB/HIV Coordinating Committee (NCC) co-chaired by
both programmes, to plan joint implementation, decentralization, priority operation
research and support to regional and facility level. At health facility level, integrated
HIV/TB care is provided to the patients through integrated services and facilitated
referrals. Over the past 6 years, policies and guidelines have been developed by the MOH
and National TB/HIV Coordination committee to facilitate harmonization of the TB and
HIV program management and include:
1) National Policy Guidelines for TB/HIV Collaborative activities (2007 with revision
in 2014)
2) TB/HIV Decentralisation framework (2011)
3) National IPT guidelines (2012)
4) National IPC guidelines – (2014 –draft)
5) 3Is guidelines (2013)
These policies and guidelines are currently being implemented by both programs with
alignment in the critical components (subsystems) of the health system namely; Health
information system (TB screening tools and referral and linkages tools), Laboratory and
diagnostic services (national sample referral and transportation system), Procurement and
supply chain management (Isoniazid delivery through the ART warehouse and ordering
systems), Health workforce (TB screening officers and expert clients) and Financing.
a) Alignment of TB and HIV strategies
Current M&E systems are disease-specific and largely paper-based however, components
that reflect integration in the TB register are: HIV testing, cotrimoxazole preventive
therapy, ART treatment; and components in the ART registers that reflect TB integration
are: TB screening, TB disease, Isoniazid preventive therapy both in the paper based and Rx
MIS. However, patients have to be doubly register and there is movement of patients
between registers depending on HIV and/or TB infection and treatment status. Currently,
through the NCC, all HIV patients with TB are registered and managed in the TB clinical
settings until completion of TB treatment before being referred back to ART clinics. This is
due to infection control concerns of treating TB in congested HIV clinics. TB screening is
being conducted in all HIV clinics and HIV patients without TB started on IPT. However
currently, only 12% of the patients eligible for IPT are accessing IPT. Harmonized
indicators were developed in line with the goals and objectives of TB/HIV collaborative
activities contained within the TB/HIV Policy Guidelines, and the NTCP is responsible for
reporting on data collected at the TB clinics while SNAP is responsible for that collected at
HIV care, HTC, and PMTCT centres. Within the RxPMIS, the TB/HIV module captures the
indicators tracked for TB/HIV. Plans for joint M&E systems have been discussed and are
being developed for both health facility and community systems. Service delivery
integration is particularly strong at community level with various cadres providing
integrated TB and HIV treatment support to the same co-infected patient.
The revised TB/HIV collaborative framework provides a new opportunity to strengthen
joint implementation. Its roll out in 2014 and 2015 will lead to significant operational and
cost efficiencies and improve effectiveness of the collaborative HIV/TB activities. The
overall goal of the policy is to decrease the burden of TBTB and HIV in people at risk of or
affected by both diseases in Swaziland through improved TB and HIV collaborative
interventions, including:


Strengthening the mechanisms of collaboration and joint management
(information sharing, planning, implementation and monitoring and evaluation)
between SNAP and NTCP at all levels to deliver integrated TB and HIV services
preferably through one stop centres;
Reducing the burden of TB in PLHIV, their families and communities by ensuring
the implementation of the Three I’s strategies for HIV/TB and early initiation of
ART in line with the comprehensive care guidelines within HIV clinical care settings
and in community;
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
Reducing the burden of HIV in patients with presumptive and diagnosed TB, their
families and communities by providing comprehensive HIV prevention, diagnosis
and treatment services in TB clinical settings and community
i) steps for the improvement of coverage and quality of services,





Implementation of the HIV/TB decentralization Framework (2013)
Use of community resource person for joint activities (CBOs, FBOs and NGOs)
Implementation of the joint minimum HIV/TB communication package currently
being piloted in Manzini region
Integration of HIV testing and TB screening within the community. A successful
model was implemented in Manzini for joint community HTC and TB screening
with a strong referral mechanism
Joint supportive supervision where counterparts from HIV, TB and the Strategic
Information Department (SID) conduct quarterly joint supervision visits
ii) Opportunities for joint implementation of cross-cutting activities
The MoH HMIS unit is currently piloting an electronic Client Management Information
System (CMIS) which utilizes a unique identifier to facilitate life-long access to a client’s
health information and includes modules for HIV and TB services. The system is able to
generate statistical reports for TB/HIV and therefore inform planning for joint
interventions. In addition, the country’s Vital Registration system is being strengthened to
support disease coding which is crucial in recording disease-related mortality data.
The Swaziland Health Laboratory Services (SHLS) coordinates diagnostic service delivery
and supply chain management in the country. The National Sample Transport System
(NSTS) system 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. The NSTS is currently equipped with 5 customised vehicles and 6 motorbikes
with an additional 6 vehicles to be procured by PEPFAR. DHL provides a courier facility
which links hubs with the National Reference Laboratories eg TB culture lab, Virology lab
and Early Infant Diagnosis. Further, there are 22 Peripheral Laboratories provide
diagnostic and treatment monitoring testing for both TB and HIV.
In 2011, Swaziland adopted GeneXpert MTB/RIF as the initial diagnostic test for patients
regardless of HIV status and has currently been expanded to 25 peripheral laboratories
with ART sites being a priority. Further decentralization of TB diagnostic services to lower
level facilities is guided by the availability of POC CD4 tests. National Laboratory Strategic
Plans are developed in collaboration with all disease programs and the different
laboratories (microbiology, virology, pathology etc.) are responsible for forecasting and
procurement.
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 and medicines and the prevention of stock-outs. The ART
warehouse also stores Isoniazhid used for IPT and dispensed together with the ARVs.
Joint capacity-building for collaborative activities includes a well-structured Task shifting
framework and capacity building of nurses through IMAI/NARTIS (integrated TB/HIV)
training. Ensuring continued competency-based education of HCW’s through clinical
mentoring, regular supportive supervision and the availability of standard operating
procedures (SOPs) and job aids, reference materials and up-to-date national guidelines is
important in ensuring quality healthcare. Through support groups for PLHIV Community
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based care and support groups and community-based organizations, TB prevention,
diagnosis, treatment and care will be integrated with those for HIV and vice versa.
Communities can be effectively mobilized to advocate for resources and opportunities to
implement TB/HIV collaborative activities, therefore it is imperative that civil society
organizations including NGOs and CBOs advocate, promote and follow national TB and
HIV guidelines, including monitoring and evaluation of TB/HIV activities using nationally
recommended indicators. The current community monitoring tools require revision to
facilitate integration, necessary for TB and HIV information needs and
comprehensiveness.
Social mobilization that generates public demand and secures broad consensus and social
commitment among all stakeholders is critical for stigma mitigation and prevention of TB
and HIV, as well as encouraging participation in collaborative TB/HIV activities. Ongoing
collaboration between the TB and HIV Programmes have enabled production of a joint
TB/HIV communication strategy and IEC materials distributed at national and community
events. The strategies include mainstreaming of HIV components in TB communication
and of TB components in HIV communication and guide implementation of these activities
and link the public to the program areas. Public Health programs in the country are
supported by the government, however due to the high disease burden of the co-epidemics,
resource constraints from government financing for the programs’ implementation has
often required substantial support from donors. NTCP and SNAP financing differs
significantly as the national HIV response ismulti-sectorial whereas TB Control remains
within the Health sector. Therefore, partner support for the two programs also differs.
Resource mapping during the strategic plan development was a joint collaboration as was
the concept note development process. Integration of TB and HIV services at national,
regional and facility level remains a priority in order to decrease the TB/HIV burden in the
country.
iii) expected efficiencies that will result from this joint implementation
Integration is a growing priority in the context of the AIDS and TB response. HIV and AIDS
are intrinsically linked to many other health problems. Integration has the potential to
improve the quality and continuity of care for those living with HIV or TB and bring HIV
services to those who would otherwise not have access to them. For some interventions,
such as prevention of mother-to-child transmission of HIV (PMTCT) or prevention and
treatment of tuberculosis (TB) co-infection, integration is clinically essential and is
supported by a wide range of evidence on its clinical and HIV Care and Treatment
integrated into the mainstream health service delivery system.
The model that will be promoted includes:
-both voluntary and provider-initiated Counseling and Testing for HIV, integrated into
primary health care (PHC), SRH, home-based care, MCH and TB services.
-TB services integrated into HIV care and treatment, including IPT, intensified case finding
and TB treatment. These services use Counseling and Testing as an access point for TB
services, although several implementation models include referral from any TB unit to the
HIV Counseling and Testing unit, indicating two-way collaboration. In addition, Swaziland
has integrated HTC in TB clinical settings.



HIV care and treatment integrated into general health services, TB Clinical settings
and community-based care (including palliative care, cotrimoxazole preventive
therapy, PMTCT and antiretroviral therapy (ART)).
Integration of family planning (FP) into services for HIV-positive individuals,
including PMTCT and HIV care and treatment.
HIV/TB care treatment and preventive outreach services integrated into other
health services for key populations at higher risk of HIV and TB exposure, who may
have different needs/interactions with the health-care system from the general
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public
In order to measure improvement in collaboration, the following milestones have been set:
Steps for the improvement of coverage and quality of services.
1. By end of 2015, all regions should have put in place a mechanism for
collaboration between tuberculosis and HIV programmes at regional level
2. By end of 2015, all regions should have strengthened the routine HIV
surveillance among TB patients and TB surveillance among PLHIV through
recording and reporting and including systematic outbreak investigation.
3. By end of 2015, reports of the planned joint supportive supervision
4. By end of 2015, at least 1 joint regional semi-annual TB/HIV review.
5. By end of 2017, regular joint data quality assessments.
Community System Strengthening for TB/HIV will be positioned in a way that harmonises
service delivery for both diseases to improve health outcomes. The community engagement
and advocacy for community system strengthening will create an enabling policy
environment for service delivery affecting the social determinants of health. Community
networks and actors capacity will be enhanced to deliver integrated services including
harmonisation of service delivery for TB/HIV. Through strengthened community linkages
and referrals between community and health facilities, reporting will be improved to
inform programming at community level, advocacy and accountability. The exiting health
based community technical working group will leverage on to further create opportunity
for better coordination of TB/HIV to improve on community capacity to support service
delivery.
The nature of the CSS intervention depends largely on the engagement and commitment
of communities including community leadership at various levels, the support of the
coordinating structures of the existing community structures and effective collaboration of
civil society actors and government. Therefore, the interventions are likely to be affected if
commitment is sustained by all actors. However, despite investing in community
capacities, sustaining these investments maybe affected by unforeseen calamities which
may affect the health outcomes of the community.
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) may improve technical efficiency by
sharing scarce resources, such as skilled planners and managers. Joint planning
and management, monitoring and evaluation, and reporting may also improve
allocative efficiency from public funds resources across interventions taking into
account the relative cost-effectiveness of services.

At the financing level, integration may improve technical efficiency by merging the
costs of separate financing systems. Co-ordinated financing systems may also
reduce perverse incentives that may be created by competing programmes and
thus impact allocative efficiency.

At the health management systems level, integration will facilitate improvements
in technical efficiency through reductions in management systems costs including
joint procurement, sharing of technical officers, joint training and supervision,
sharing of information, education and communication materials, and joint
management information systems.

At the facility level, integration can contribute to reductions in facility costs
resulting from joint utilization of fixed factors of production, “one-stop model” or
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facilitated and systematic referral between services.

For patients, integration will lead to less fragmented services, higher levels of
continuity 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
b) The barriers that need to be addressed in this alignment process.
i)
Currently the planning cycles are different for the different programs, there is
need to further align.
ii)
Guidelines need to be harmonized as current guidelines are developed
separately although collaboration.
iii)
Lack of regional TB/HIV coordinating committee
iv)
Different funding streams for the two programs
v)
The central questions currently concerning most optimal efficiency model for
Swaziland context
Lack of funds for investment in country-based operational research to support future
development of policy and programming in this area.
SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND
SUSTAINABILITY
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 (75% 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
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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 $12M.
These costs and commitments result in a funding gap of roughly $52M 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 2012-March 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 were well funded while others had significant 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
- 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
OVCs. 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
TB and HIV Concept Note Swaziland Draft III
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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
BehaviourChange, PMTCT, Gender Based Violence and Male Circumcision were included
as part of the ‘ask’ since the programs believed that there are sufficient needs for these core
programmatic areas.
TB Program: While the primary focus of the Government of Swaziland has been the HIV
program, the Government has demonstrated an increasing level of financial commitment
to the TB program. A large portion of the TB program’s budget is financed by the
Government and the MoH has clearly stated 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 $32M 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 ($23.4M), the country is meeting the 40%
counterpart financing requirement needed to access the full TB allocation of GF funding.
Note that previous communications regarding counterpart financing for the TB program
to the Global Fund country team were based on approximate calculations that were being
revised. 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
x-rays, Maternity specific machines as well as on refurbishment of TB center, health
centers, and training institutes.
2) Other: Approximately $3.71M will be spent on HR (cough monitors, co-infection
coordinators, technical assistance for MNOC, infection control), vehicles,
healthcare waste consumable, 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. Analysis shows 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
TB and HIV Concept Note Swaziland Draft III
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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
the health sector overall. 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
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 with MSF contributing 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 government funding complements
the donor funding and covers primarily those areas that are not covered by any of the
partner funds. For the HIV program, the government has previously funded 100% of ARVs
such thatGlobal 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. Details on the request for ARVs needed 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 high-impact
interventions. In addition, Global Fund funds will be used to scale-up a variety of different
programs such as the implementation of viral load testing on the HIV side, increased case
detection and diagnosis for MDR-TB, as well as implementing a variety of joint HIV-TB
activities.
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. Currently, the Government of Swaziland is the
single largest contributor in the HSS space, however, the Government alone is unable to
fund all the critical interventions that are required to build a strong health system.
Therefore, programs have decided to reallocate significant proportions of their allocations
to support health system strengthening interventions. For example, $1.9M has been
reallocated from the disease programs 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 $36M to help bridge the gap in this area by focusing on
the scale-up of VL testing, however, a variety of other ART related activities’
implementation may be delayed due to lack of funds. 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 in
the next few years, the Government is open to discussing a strategic shift in funding based
on the results of the country’s initial response.
The single largest gap within the TB program falls under objective 4, which deals with
MDR-TB. The country is currently requesting $12.27M 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.
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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
Compliant?
i. Availability of reliable data to assess
compliance
☒Yes
☐ No
ii. Minimum threshold government
contribution to disease program (low
income-5%, lower lower-middle
income-20%, upper lower-middle
income-40%, upper middle income60%)
☒Yes
☐ No
iii. Increasing government contribution to
disease program
☒Yes
☐ No
If not, provide a
brief justification
and planned actions
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 HIV 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 in to strengthen service delivery and PSM i.e.
by employing doctors, laboratory technologists and improving procurement systems
for drugs and related commodities.
The Govt 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 the OVCs are
adequately cared for in the coming years. The MoH is also looking for sustainable
enablers that will capacitate the OVCs 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 the vaccine costs show that it is expensive and it
will consume a significant proportion of Governmentresources 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).
TB and HIV Concept Note Swaziland Draft III
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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
organizations.
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
the respective disease programs. Both the HIV and TB program undertook an extensive
exercise to develop their NOPs ahead of the concept note submission and costed each
of the activities within the NOPs to determine the full cost of the national response per
disease area.
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 for 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 on 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:
The program leveraged available data for Global Fund’s budget period 14 through 25
covering January 1 2011 through March 31 2015for the HIV grant to calculate the funds
committed by the Global Fund through the TFM process and Global Fund’s budget
TB and HIV Concept Note Swaziland Draft III
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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 crosscutting 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(file name/worksheet name)
PMTCT(file name/worksheet name)
Treatment care and support(file name/worksheet name)
TB care and Prevention(file name/worksheet name)
MDR/TB(file name/worksheet name)
TB/HIV(file name/worksheet name)
--------------- ------------ ---------------- ------------ ---------- ------------ ---------------- ------Health Systems Strengthening (HSS)
(a) Health Information Systems and M&E
In line with one monitoring and evaluation system, reporting to global fund through
NERCHA is the key responsibility of this MOH. Over the years this office has received
capacity building mainly from PEPFAR. It is through this strengthening that the unit has
been positioned to build M&E systems in health.
The key gaps include lack of a standardized registration and tracking system, duplication of
data, delays in reporting and weak harmonization of tools and integration of data to the
HMIS. To address this gap, a new client management information system (CMIS) designed
to capture client information at service exit on key indicators is being piloted. This will serve
to integrate and coordinate patient care toward improved clinical outcomes including
additional key health programs (Male Circumcision, NCDs, Malaria, Maternal & Neonatal
Child Health, and others). The targets are: 90% timeliness of report submission, 90%
completeness, and 95% accuracy of data by 2018. The pilot phase is supervised by a crossministry/cross-program steering committee who monitor on the quality and governance
TB and HIV Concept Note Swaziland Draft III
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issues. After the pilot phase, this will be integrated to the Strategic Information Unit of the
M&E dept of the MOH.
To run the system, central WAN and LAN installation and computers with servers are
required per facility. Currently, the system is being implemented in 47 facilities through
PEPFAR funding. There is a plan to roll it out to additional 247 public health facilities
throughout the country to be funded by government and partners including the GF.
The Global Fund is requested to cover within the allocation: 1) 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. For the above allocated
amount, key activities include training of technicians and technical assistance for monitoring
and in case of major maintenance in collaboration with private IT companies and
government computer services department within the Ministry of ICT.
For an efficient running of the unit the national office needs four additional senior M&E
analysts Government position E3. The regions each need one additional M&E Analyst,
Government posts C6, (a total of four). These positions are critical government positions.
(b) Procurement and Supply Chain Management:
The main identified gaps in the PSM are largely related to storage capacity and systems
management. The gaps are even more pressing due to projected increase in demand for
health products, especially for HIV, TB and Malaria which put additional pressure on a health
supply system that is already strained.
Currently, there are three functional warehouses; namely the central medical store, ART
warehouse (rental), the national lab warehouse; used for storage and distribution of health
products throughout the country. The required storage capacity for each is listed below;



Central Medical Store Facility: for general medical supplies, with 2800m2 purpose built
storage space, however, its current requirement is 7000m2
ART warehouse: The rented Warehouse with a capacity of 5300m2 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)
There are urgent needs to improve the storage capacity of warehouses, build capacity in
procurement and logistics management, quality control, and transport and distribution
mechanism. While the interim plan is to refurbish, improve efficiency and warehouse
management system, the long term plan is to acquire land and integrate PMS into one
centralized mechanism. To address this, a draft supply chain integration plan is being
finalized to ensure a unified and integrated procurement, storage and distribution of health
commodities (Draft Sept 2014).The MoH has evaluated options on whether to buy a
warehouse or build a new one on the current central warehouse, decisions from the relevant
ministries mandated to finance and public project management.
The request for the GF is to support refurbishment within the allocated amount, capacity
building in procurement and supplies management, strengthening quality assurance, and
distribution.
(c) Service Delivery:
The current plan is to implement the EHCP at all public, private and mission hospitals, clinics
and health centers which account for 146 of the 287 facilities. However, there are a number
of challenges to the service delivery system that are impeding the capacity to deliver the
required health services; namely;



The health facilities are not offering the package according to their level of care
Key infrastructure and equipment are not available as expected.
No standard method of measuring and monitoring the quality of care given.
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As a result, the effective implementation of the EHCP will require investments in
infrastructure, equipment, human resources and capacity building. Government has
committed to gradually address staff shortages in facilities as well as continuing to provide
formal training for the relevant cadres, however, gaps persist in the areas of infrastructure
and equipment.
Using funds from the EU/World Bank joint TB/HIV project, MoH has costed the initial
investments needed for the implementation of key interventions to achieve provision of
essential health care services. Findings from 17 facilities show that all facilities need
refurbishing or renovating (Gap analysis on infrastructure and equipment 2013). Currently
MoH through a World Bank loan is rehabilitating maternity units at the National referral
hospital and all health centers and construct operating theatres in all the health centers. In
the same TB/HIV project there is also a plan to renovate some primary health care facilities
with the goal of increasing coverage of HIV, TB and Malaria in a comprehensive health
service delivery model. The request to the Global Fund will complement the existing
resources and will be earmarked for areas with high disease burden and volumes.
(d) Health and Community Workforce:
In 2012, Swaziland developed and costed its first Human Resources for 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 plan highlighting the activities, targets and time
period was developed. The workplan identifies, among others, recruitment and retention,
training, and human resource management in a phased approach. The training focuses both
general and specialized training for different categories of health professionals and technical
support at workplace to ensure that the country is well positioned to address issues relating
to the three diseases and also meet maternal and child health development goals (HRH plan
2014).
The current practice of orientation/induction of new employees in policies and procedures
so that they can undertake their role effectively is weak. Improving orientation will ensure
that Swaziland has a high-performing health work force to adequately respond to the HIV,
TB and Malaria epidemics.
At community level, the 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. Recognizing this, the HRH plan emphasizes on training and retraining of primarily level health workers in an integrated TB and HIV management. The
curriculum for community health workers also incorporates essential maternal and child
health skill building.
The MoH is currently investing its sources and receiving financial and technical support from
other partners to implement this plan. However, the MoH has funding gaps for training of
key management positions which also limits the country’s ability to manage its health system.
Thus, the request for the GF is to support training of administrators, to conduct orientation
workshops, and training of primary health care workers.
--------------- ------------ ---------------- --------- ------------ ---------------- ---------------Community Systems Strengthening (CSS)
A number of policies have been developed within different programs across sectors to
support building an institutional capacity and strengthen an enabling environment for
service delivery at community level (Table 2). Structures have been established to support
programme delivery at community level such as Umphakatsi, KaGogo Social Centres (KSCs),
Social centres (in urban areas) and Neighbourhood Care Points (NCPs). KaGogo centres
serve as coordination centres for HIV services. As described in 1.d above, the different
community actors and structures are involved in community health services. However, there
are gaps in coordination of TB, HIV and Malaria, posing a challenge for roll out of the
essential package for health services (EPHS)-which aims to attain an integrated and
equitable access to healthcare. As such, practicality of the “Three Ones principle”, i.e. one
plan, one coordinating body, and one monitoring structure, remains a challenge.
TB and HIV Concept Note Swaziland Draft III
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The main challenges and gaps in community systems include;








Leadership , governance and technical capacity weaknesses at CSO level
Lack of a comprehensive framework on community systems strengthening
Weak coordination response among the different actors and structures
Weak implementation of policies and strategies
Lack of guidelines on community engagements in particular to health services.
Lack of standardised service packages among service providers and undefined roles
and responsibilities at community level
Poor referral linkages of clients from community level to the health facility level
Lack of monitoring/reporting of health care services provided at community level.
To address the above challenges, there is a plan to develop a CSS framework which will
provide a platform and serve as a road-map to coordinate and delivery community services
through contribution of community actors.
Currently, PEPFAR funded organizations, namely Health Communication Capacity
Collaborative (HC3) and Mother-to-Mother are supporting activities including small
business development, community mobilization, and PMTCT. The local community
mobilizes resources through community-public partnerships including from grants and
volunteer labor and financial contributions. However, the current activities and resources
short fall of the needs to address the above gaps.
The GF request is to strengthen community mobilization, coordination, referrals and
linkages, building capacity for monitoring of services delivered at community level.
Moreover, to ensure sustainability of community systems, there is a need to impart small
business skills, link them to saving/credit and revolving fund schemes.
Table 2 Summary of community services and plans for scaling up
Current activities
Planned scale-up activities
HIV/TB programs: mobilization, health
education, treatment and adherence support;
and follows for program services
Integrate services and ensure better
coordination among community actors
and link to health systems
Community
based
monitoring
for
accountability:
communities
conduct
monitoring activities and report to different
projects; no standard reporting format, nor flow
mechanism. Feed back to communities and
linkages to facilities remains weak
Adapt a harmonised monitoring and
reporting system with clear linkages to
health facilities, national level and
partners
Social
mobilisation,
collaboration
and
coordination: Currently stakeholders use nonstandardized curriculum; coordination is
fragmented.
Develop a CSS framework and
operational plan that clearly defines
tasks, and a standard curriculum.
Sustainability is at risk due to lack of incentives
to retain community volunteers
Building institutional capacity for leadership,
resource
mobilization
and
program
management by stakeholders with little focus on
systems building
TB and HIV Concept Note Swaziland Draft III
Scale-up economic empowerment for
community volunteers to sustain their
work
Develop standard guidelines, manuals
and train community leaders in essential
skills for leadership and management
03 Oct 2014│ 39
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
Overview: Preventing new HIV infections in Swaziland is vital in turning the tide on the
epidemic and achieving treatment and care targets. HIV disease burden remains high for
Swaziland as illustrated in section 1. Swaziland has set its goal to reduce new HIV infections
and AIDS related deaths by 2015 by 50% among adults while eliminating new infections
among children and keeping their mothers alive.
Objectives
1) To improve the quality of life of PLHIV through treatment and treatment as
2)
3)
4)
5)
prevention.
To increase the uptake of VMMC among all eligible men
To ensure correct and consistent condom use by all sexually active people
To strengthen public awareness and comprehensive knowledge of HIV risks and
vulnerabilities to increase
To improve availability, access and utilization of HIV Prevention and treatment
services by key populations
3.2.1.1. Prevention
HIV testing and counselling (HTC): the intervention area has four strategic priorities
aimed at ensuring that all children, women and men get tested and those who are HIV
positive are linked to treatment, care and support services.
To achieve the above objective, activities including demand creation using innovative
approaches including 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), will be used to increase availability of HTC services. These will be complemented
by risk reduction counselling in case of multiple and concurrent partnerships,
intergenerational sex, unprotected sex and other risk behaviours such as anal sex).
Moreover education for PLHIV on the benefits of couple testing and disclosure will be
conducted.
Currently, there is no funding gap for HTC; and thus no request made for GF funding.
Social and behavioural change: 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.
Activities including structured interpersonal communication activities to identify and
adopt community models appropriate to the local context. To complement this, public
awareness campaigns and peer education, mass media messages and special events
targeting the public will be implemented. Currently, in addition to the government roll-out
implementation national mass media and community-based campaigns, UNFPA is
supporting SRH dialogues targeting young people in Shiselweni region; PEPFAR is
supporting SBC interventions targeting adolescents and young women, adult males, MSM,
and sex workers.
TB and HIV Concept Note Swaziland Draft III
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The GF is requested to support the implementation of structured interpersonal SBC
activities targeting young women and girls including for in and out of school youth. These
include training (255 teachers, 515 volunteers) and recruitment of communication
personnel, peer educators and group discussions. As part of this, the GF will facilitate the
expansion to cover all 255 secondary schools and 293 out of 360 communities. Global fund
will also support the development and printing of information packages to be used in the
intervention. The request is within allocation.
The expected outcomes are:
- Increased personal risk perception
- Adoption of safe sexual behaviors
- Improve use of available services
Gender based violence: Intensify the provision of comprehensive health services for the
management of GBV cases.
To achieve the above, interventions focusing on prevention and management of GBV will
be implemented. Currently, the government is expanding the one-stop centres into three
regions including provision of referral and access to post exposure prophylaxis. Public
awareness on GBV is being implemented by the Swazi Action Group Against Abuse
(SWAGAA) through partners funding including PEPFAR, UNFPA and UNICEF. The MOH
in collaboration with the Ministry of Justice has adopted a national guideline and a training
manual for multisectoral response to GBV.
The GF is requested to complement ongoing activities specifically recruitment and training
of three site coordinators for the newly established one stop centers and a six months
training of six health care workers on forensic nursing in a South African tertiary
institution. In addition support is requested from the GF to complement SWAGAA efforts
on creating community awareness by scaling activities to cover the country. The amount
being requested is within allocation.
The expected outcomes are:
-
-
To reduce prevalence of GBV
Expansion of counseling, legal, HTC and post-exposure prophylaxis
Condoms promotion and distribution: Ensure correct and consistent use of
condoms by sexually active people
The national plan identifies key strategic priorities to achieve the above objective
including strengthening forecasting, procurement and supply chain management;
expansion of condom distribution outlets, targeting key populations, including
young people 15-24 year olds, men who have sex with men, sex workers and
discordant couples using multiple modalities including community structures. The
Government will be refurbishing the warehouse to improve storage at CMS and
service delivery points. UNFPA has committed to procuring 10million condoms
annually; PEPFAR has allocated a budget of USD1million for procurement and
promotion of condoms for youth and key populations. AIDS Health Care
Foundation (AHF) has committed to procuring 4.4million condoms annually over
the next 3 years. This commitment covers the total need for condoms as forecasted
in the National Quantification Report 2013 and is in line with the e-NSF targets.
However, targeted distribution and promotion remains a gap.
Global Fund support is requested to purchase and install four vending machines to
be placed in strategic areas (Hot Spots) for 24 hours condom availability. The
country is also requesting support to purchase 600 branded bags to facilitate
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 41
condom distribution at community level, which will increase visibility of condoms.
This request is within the allocated amount.
Voluntary Medical Male Circumcision: Strengthen and decentralize MC services
especially for neonatal and males aged 10-35 in health and non-health facilities.
The national plan aims to increase uptake of VMMC among all eligible males. To
achieve this target, the current program will be scaled-up and expanded through
decentralization of the program to more facilities, out reaches, and special
campaigns for school children. 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.
The government is provides the health facilities and health workers and working
with partner agencies to build institutional capacity. Currently, PEPFAR is
committed for 5 yrs support to scale-up outreach and integration of services to more
health facilities, school targeted campaigns, and placement of 60 Interpersonal
Communication Agents (IPCs), and MC motivators to drive demand for MC.
The GF request is specifically for mobile clinics to scale up EIMC and VMMC
through mobile outreach services and engagement of MC dedicated teams on a
quarterly basis for Back To School and MC Friday campaigns. Moreover, the fund,
as indicated under the HSS and CSS, will support improving reporting and
monitoring system to link both community and facility-based services. This request
is within the allocated amount.
Key populations: Develop and implement customized strategic interventions
targeting most-at-risk populations including harm reduction.
Currently customised interventions targeting most-at-risk populations have limited
coverage. PEPFAR provides lubricants and supports peer education; mentorship
and condoms distribution. A size estimate study is underway which will further
inform programming. PEPFAR will also be supporting sensitization of law
enforcement officers on the rights of key populations to access services (including
health and legal aid) until 2017.
Most activities for key populations are covered from government and other partner
agencies, notably PEPFAR. Thus, funding from Global fund is requested to train
health and community workers to integrate key population services to their work,
strengthen customized services and peer education for sex workers, MSM, and
mobile population groups. The amount is within allocation.
PMTCT: Intensify the prevention of HIV transmission from women living with
HIV to their infants’ post-8-weeks.
As part of the PMTCT elimination agenda, emphasis will be on prevention of new
infections among children while keeping their mothers alive. Primary prevention
interventions will be integrated at PMTCT sites to ensure that pregnant women who
are not HIV positive remain HIV negative. Services to avert unintended pregnancies
amongst PLHIV and teenage girls and to prevent transmission from pregnant
mothers to children will be scaled up. Swaziland will accelerate the roll out of option
B+, in addition to providing ART to all children less than 5 years regardless of CD4
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 42
and WHO stage. All infected mothers will be offered ARV prophylaxis to prevent
MTCT. Communities will be mobilised to support PMTCT clients and in particular
encourage men’s involvement in PMTCT interventions. These activities will be
supported by the government and partners.
Procurement of FP commodities is fully supported by government and UNFPA.
Global fund support is requested for training of 500 health workers on new modes
of delivery of FP methods and decentralization of FP into ART settings. It will also
support to recruit and train 132 mentor mothers and expert clients for deployment
in 33 high volume facilities (with a load of > 20 pregnant women a month). A
stipend of USD 113 will be provided for these cadres for 3 years, and USD10 per
month to the 33 facilities for 3 years, for airtime to support follow-up of mother
baby pairs. The request is within the allocation limits.
Table 3 Funding request for priority strategies under prevention module
Strategic
objective 4
2015
2016
2017
Total
eNSF
SBC
Strategy 3
1,059,316
799,128
847,09
0
2,705,535
132,670.8
5
125,113.
77
23814
85,182
252,93
0
70,958.
98
424,691
161,301
627,30
8
159,744
948,353
337,947
358,685
.45
1,079,773.
57
NOP
12.4/5
%
Fundi
ng
48.2%
GF Supported priority activities
5%
Train 500 health workers FP methods, Train
132 mentor mothers and expert clients, Recruit
132 mentor mothers and expect clients,
Incentives to 33 facilities for airtime to be
used for follow up of mother baby pairs
7.6%
Train MC champions from 16 national soccer
teams, Sensitize 293 communities. Provide MC
promotion and edutainment targeting 293
communities over 3 years, Use mobile
technologies to reach 50,000 people per year
on MC promotion and related HIV prevention
16.9%
Six months training of 9 nurses in forensic
nursing, Train 172 community cadre on GBV
per year, Coommunity sensitization on GBV to
cover 293 over the 3 years
19.2%
Train 16 youth centres coordinators and 550
existing community health cadres. Procure 566
condom carrying bags and vending machines
for hot spot areas (13)Procurement of condoms
(10million)/year
3.2%
Conduct trainings for 400 peer educators from
all key populations sub groups. Train 100 health
care workers on management of key population
health issues
SBC
eNSF
PMTCT
strategy 4
281,598
NOP PMTCT
11.1
eNSF
MC
strategy 2
NOP
16.2,
21.1
MC
19.1,
eNSF GBV
strategy 4
NOP GBV 6
eNSF
Condom
strategy 2/3
383,140.6
4
NOP CPD 6,
7
eNSF
key
population
strategy2
43,236
65,533
69,555
178,324
1,864,846
2,207,9
60
1,529,8
47
5618275
Train 255 school-based, 293 community
facilitators, Development and printing of
information packages and teaching aids,
Recruit 255 school-based and 293 community
based facilitators, Conduct Quarterly review
sessions for 255 schools and 293 communities,
NOP KP 5.1,
13.1
Total
100%
3.2.1.2. Anti-retroviral therapy (ART)
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 43
Objective: to improve quality of life of PLHIV through treatment
Outcome: Percentage of adults and children with HIV still alive and known to be on
treatment 36 months after initiation of ART is increased from 68% for adults in 2011 to
75% in 2015 and 80% in 2018 and from 66% for children in 2011 to 70% in 2015 and 75%
in 2018
NOP Activity 8.21: Provide ART for PLHIV across all delivery channels:
As per the 2013 WHO Consolidated HIV Guidelines, patients with CD4 cell counts
<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. 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 ggovernment 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 paediatric 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 185,194 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. The funding request is within the allocated
amount.
NOP Activity 8.26: 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 lab reagents but will
not be able to support the cost related to rapid scale up of ART provision.
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 and this scale up will mostly cater for the remaining 3
regions
The country is requesting Global Fund (within allocation) 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 to handle the load in
volume of VL and EID tests
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 44
Above allocation: the country is requesting (USDXX) for support to fund reagents for
haematology and chemistry to support the scale up of ART provision.
NOP Activity 8.17 - Conduct HIV Drug Resistance (HIVDR) Activities:
HIV Drug Resistance (HIVDR) monitoring will be strengthened to generate evidence 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).
The country is requesting Global Fund (Within Allocation) for genotyping tests for future
surveys. These costs will cover about 260 participants per survey. Four surveys will be done
between 2015 and 2017. This is within allocation amount.
NOP Activity 8.5 - 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.
The Global Fund is requested (Within Allocation) 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 85 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.
NOP Activity 8.24 - 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 mother-baby pairs
will facilitate identification and their enrolment into care.
PEPFAR and Clinton Health Access Initiative (CHAI) are supporting government to set up
infant surveillance systems that will be linked to the national HMIS. They are providing
financial and technical support.
Though identification is 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 request for Global fund to support this activity.
NOP Activity 8.5: 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.
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 45
Table 4 Funding request for priority strategies under treatment, care and support (ART)
NOP Strategy
Year 1
Costs
Year 2
Costs
Year 3
Costs
Total Costs
%
Funding
GF Activities
NOP Activity
8.21:
$23,133,393
$25,704,717
$28,423,853
$77,261,963
Funded:
78%
Procurement of ARVs for
paediatric and 20% of the
adult population
NOP Activity
8.26:
$12,042,396
$12,709,400
$13,417,282
$38,169,078
Funded:
46%
Procure reagents to support
scale up of VL monitoring
Recruit and pay salaries for
5 lab technologists and 1
data clerk
Procure equipment to
facilitate VL testing scale up
Procure reagents for
haematology and chemistry
to support scale up of ART
provision
NOP Activity
8.17
-
$221,239
$115,196
$336,435
NOP Activity
8.5
$692,374
$780,533
$995,164
$2,468,071
Genotype tests for
approximately 1040
samples
Funded:
0%
Procure corn soya blend to
support food by prescription
for PLHIV and TB patients
3.2.2. Tuberculosis
Objective 1: To diagnose and enrol on treatment at least a total of 40,000
TB cases by 2019
Strategic Intervention 1.1: Strengthen active TB case finding in communities
The program acknowledges that engagement and strengthening of existing community
structures in fight against TB will be vital in ensuring community buy-in and local support
of TB screening efforts. Therefore the program has prioritized interventions targeted at
increasing awareness for TB and the scale-up of active case finding at the community level.
The Program will utilize existing community structures including treatment supporters and
adherence officers who will be trained on patient follow-up and active case finding in
communities.
The Global Fund will be requested to provide support for salaries for treatment supporters
and adherence officer. The government of Swaziland has already committed to supporting
a majority of the remuneration for Rural Health Motivators, whose capacity will
strengthened to include TB screening in the communities.
In conducting the community campaigns, government supported facility HR will be utilized
for these activities in the relevant communities to facilitate acceptance and social
mobilization and the government has committed funds to support the national DOT
coordinator salary.
Strategic Intervention 1.2: Strengthen contact investigation in communities
The NTCP plans to intensify efforts to follow-up and trace contacts of TB patients back to
their households and communities. This strategy will require a multi-disciplinary targeted
approach; which include engaging constituencies such as prisons, mines and mining bodies
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 46
to screen for and link all TB suspects to diagnostic centres and ultimately TB care. The
program has prioritized contact investigation amongst paediatric contacts through
strengthening the follow-up, rapid diagnosis and appropriate management of adult TB
cases.
The government of Swaziland will support facility HR salaries and support is requested
from the Global Fund for Adherence Officers and Treatment Supporters’ salaries to enable
quality contact tracing activities.
Strategic Intervention 1.3: Strengthen intensified TB case finding in all healthcare settings
Efforts to integrate TB screening as part of the routine clinical assessment for all patients
are already underway. The plan in this grant period is to set-up TB screening so that TB
cases are diagnosed early and patients are started on treatment timely. The program have
prioritized coverage of the main entry points in major health facilities with cough officers
to provide intensified case finding and screening services, including PMTCT and ART
initiation sites.
The government of Swaziland will contribute towards nurses and clinician salaries, as well
as printing and distribution of recording and reporting tools for contact tracing. The
request from the Global Fund will support the salaries of Cough Officers who will be
placed in all major entry points in big facilities to ensure coverage of TB case finding.
Strategic Intervention 1.4: Strengthen and expand TB Laboratory network
The NTCP plans to expand and strengthen the existing laboratory network with a focused
on improving peripheral laboratory coverage especially in under-served and hard to reach
areas. This will be achieve through the upgrade of mini-labs to fully-fledged TB peripheral
labs. During the grant period the NTCP aims to improve the laboratory system
infrastructure, infection control practice and quality control measures towards full
accreditation. The scale-up of rapid molecular diagnostics as well as the expansion of
culture services to include second line DST, are imperative to blocking systemic leakages
contributing to the diagnostic-treatment gap as well preventing transmission of drug
resistant strains.
The Government of Swaziland has committed to funding the National TB Reference
Laboratory (NTRL) Manager salary and in collaboration with development partners has
upgraded the NRL to a Bio-Safety Level 3 diagnostic laboratory (BSL3). The NTRL has
recently with continued GF support capacitated Lab Technologists on second line drug
susceptibility testing (SDL)
Support from the Global Fund will facilitate the ongoing upgrade of mini laboratories as
well as peripheral laboratory infrastructure improvement to meet minimum biosafety
standards. Salaries support for laboratory technicians, microscopists and the NTCP
laboratory focal person will also be requested from the Global Fund.
Development partners, i.e. MSF, URC and FINDx, have committed to supporting on-going
capacity building of all laboratory staff and PEPFAR has committed resources targeted at
strengthening of the national sample transportation system.
Strategic Intervention 1.5: Laboratory quality assurance and accreditation
Quality assured lab testing is a critical component of accurate TB diagnosis, to this the
NTRL has enrolled in quality assurance programmes for smear microscopy and culture
testing. Enrolment of GeneXpert MTB/RIF in a quality assurance programme is a gap
which is being addressed with technical assistance form our developmental partners.
The NTCP Technical partners have committed to supporting ongoing training and
supervision of lab staff on QA, as well as technical assistance to support the national and
peripheral labs in reaching full accreditation.
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 47
The country will requested the Global Fund to support an uninterrupted supply chain of
laboratory consumables and commodities including GeneXpert cartridges and reagents,
culture and DST kits (first and second line) as well as replacement and maintenance of a
BACTEC MGIT 960 system to support second line DST
Strategic Intervention 1.6: Strengthen referral and linkage-to-care of TB patients
In order to reduce transmission at the community level, the NTCP has prioritized the
identification of avoidable delays within the diagnostic pathway through Implementation
science research. This involves strengthening the integration of laboratory and clinical
systems to facilitate rapid, accurate diagnosis of TB and prompt initiation of appropriate
therapy.
Through support from technical partners, the Swaziland Health Laboratory Services
(SHLS) is currently rolling out the Laboratory Information System (LIS), which will reduce
the turnaround time of results from lab to the clinical setting. On-going capacity building
of lab staff includes training on analysis and interpretation of monthly statistics to improve
lab performance
Additional funding assistance from the Global Fund will be requested to facilitate
integration of manual and electronic laboratory registers.
Strategic Intervention 1.7: Strengthen the integration of care for childhood TB with other
child care services
To address this challenge, the NTCP has prioritized childhood TB diagnosis and
management with plan to integrate childhood TB screening in all level of the Swazi Health
Care System. This will include development of program guidelines specific to childhood TB
and intensified training and supervision health care workers for the same. The Government
of Swaziland has committed to provide support for remuneration for the national paediatric
TB coordinator. Additional funding will be requested from the Global Fund to support
capacity building of all health care workers and procurement of paediatric specific
diagnostic supplies.
Table 5 Funding request for priority strategic interventions under objective 1
Objective 1
2015
2016
2017
TOTAL
$3.53
$2.89
$3.07
$9.49
%
Funding
Program Activities as per
Strategic Plan
Within Allocation
Strategy
Intervention
1.1
$890,417.95
$725,841.98
$829,717.92
$2,445,977.86
Increase TB awareness in
communities and create
demand for contact
investigation
Above Allocation
Procure GIS Tracking Device
(Garmin Etrex 30).
Within Allocation
Strategy
Intervention
1.2
No prioritized activity to be
funded under GF
$12,783.12
$0.00
$0.00
$12,783.12
Above Allocation
Identify, adapt, sustain and
scale up best practices on
childhood contact tracing and
linkage to TB care.
Within Allocation
Strategy
Intervention
1.3
$11,114.27
$11,781.12
$12,513.39
$35,408.77
$1,226,143.4
4
$934,533.40
$1,031,526.82
$3,192,203.66
TB and HIV Concept Note Swaziland Draft III
Expand and strengthen
systematic screening in all
OPDs, PHUs and diabetic
clinics inclusive of pediatric
specific interventions
Within Allocation
03 Oct 2014│ 48
Upgrade mini labs to
TB Lab diagnostic sites
Strategy
Intervention
1.4
Above Allocation
Improve laboratory
infrastructure in 11 sites to
meet minimum biosafety
standards and work
Within Allocation
Strategy
Intervention
1.5
$784,567.20
$787,876.90
$893,559.07
$2,466,003.18
Strategy
Intervention
1.6
$142,813.46
$47,144.05
$49,972.69
$239,930.20
Ensure uninterrupted supply
chain of lab consumables and
supplies.
No prioritized activity to be
funded by GF
Within Allocation
Strategy
Intervention
1.7
$224,962.95
$238,460.73
$252,768.37
$716,192.04
Conduct capacity building
activities for all health care
providers to identify
presumptive TB in children,
collect appropriate specimen
samples and refer for
bacteriological testing
Objective 2 To provide treatment for all diagnosed TB cases and achieve at least 90%
treatment success rate by 2019
Strategy 2.1 Expanding access to TB treatment
The number of Basic Management Units (BMUs) will be increased nationally to 145 sites
by 2019 with prioritization of sites providing HIV care without TB services.
Decentralization of BMUs to lower level facilities within the communities is an ongoing
activity supported by Government for HR and World Bank for infrastructural
refurbishment and IPC implementation.
Furthermore, the NTCP will maintain capacity building activities of Healthcare workers on
TB screening, diagnosis and management. This will include the review and strengthening
of the training manuals used on pre-service and in-service TB management trainings.
Government will continue to support the National DOTS Coordinator’s salary, while the
National TB Pharmaceutical Coordinator and Regional TB/HIV Coordinator’s salaries are
pending absorption into the Government establishment.
With support from Global Fund, a mobile clinic staffed by Government supported HCWs
will be procured to provide TB screening, onsite diagnosis and treatment initiation for
under-served, hard to reach areas and TB hot-spots. Diagnosed patients will be linked to
the nearest clinic for follow-up.
Strategy 2.2 Strengthen treatment adherence and support
In expanding care and support services, trainings of health care workers on
treatment adherence and monitoring are just as essential as trainings on quality assurance
(QA) and quality improvement (QI) to strengthen periodic data collection and analysis as
well as service audits at all levels. To facilitate good treatment outcomes, technical partners
have committed to fund the afore-mentioned trainings as well as strengthening of
supportive structures at facility level. These structures include nutritional support and
counselling to malnourished TB patients, psycho-social support to patients and families
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 49
through the involvement of social workers and health education on the importance of
treatment adherence and proper nutrition.
Global Fund has previously provided funding support for community Treatment
supporters’ salaries who are trained on DOT, recognition of adverse reactions and contacttracing. At facility level, Adherence Officers liaise with Treatment supporters and Facility
staff on defaulter tracing and screening of household TB contacts. With ongoing support
from GF, the NTCP aims to ensure coverage of all BMUs with Adherence Officers while
Government has committed to support the salaries of four National TB Statistical clerks as
well as four Regional TB/HIV Coordinators and four Regional TB Data Clerks, pending
absorption. The Regional TB Data Clerks and TB/HIV Coordinators will train, mentor and
supervise the community Treatment supporters and Adherence officers.
Strategy 2.3 Engagement of communities, civil society organizations,
public and private care provider
According to the STOP-TB Mapping of TB service provider’s report (2007) approximately
30% of the Swazi population are served by private care providers, including Traditional
Healers, private Medical Practitioners and Pharmacists, Non-Governmental Organizations
(NGOs), Community-Based Organizations and Faith-Based Organizations (FBOs).
Therefore, strengthening the training and engagement of private care providers,
pharmacists and Civil Society Organizations (CSOs) on TB diagnosis and management,
remains a critical component of successful TB control.
GF has supported the establishment of a Swaziland STOP-TB Partnership (SSTP, 2009)
including salary support of staff to coordinate the Private-Public Mix (PPM) and ensure
systematic, standardized management of TB patients in the country. Funding support will
be requested from GF for continuation of SSTP staff salaries and activities aimed at
strengthening the PPM as well as training of all private care providers on the National TB
Management guidelines.
Strategy 2.4 Ensure an uninterrupted supply of 1st line Anti - TB
medicines to treat all diagnosed patients, including adverse events
The Government of Swaziland has committed to ensuring that all diagnosed TB patients
receive free TB therapy (First and Second-line drugs) and support including inpatient
management and adverse event management. This support includes the National TB
Pharmaceutical Coordinator and National TB Pharmacy Technician’s salaries, pending
absorption. GF has also previously provided extensive financial support for the
procurement of second-line drugs.
Previous support from GF includes storage facility upgrades at BMUs to ensure quality
storage conditions. Further support will be requested under the Health Systems
Strengthening (HSS) module to facilitate strengthening of Procurement and Supply Chain
Management (PCSM), including capacity building and supervision of healthcare workers to
ensure correct storage of drugs at facilities as well as timely forecasting, quantification and
supply planning to avoid unnecessary medicine stock-outs.
Table 6 Funding request for priority strategic interventions under objective 2
2015
2016
2017
TOTAL
$1,700,00
$1,900,00
$6,700,00
TB and HIV Concept Note Swaziland Draft III
% Funding
GF Interventions
Govt: %
03 Oct 2014│ 50
Objective
2
$3,000,0
00
Strategy 2.1
$700,000
GF: %
Other: %
Govt: %
$620,000
$670,000
$1,990,00
GF: %
No prioritized activities
Other: 0%
Govt: %
Strategy 2.2
$1,690,00
$510,000
$580,00
$2,780,000
GF: %
Reinforce adherence to TB treatment
Other: 0%
Govt: %
GF: %
Other: 0%
Within allocation
Strengthen Public Private Mix (PPM)
and PP coordination to implement
National TB guidelines
Engage private providers and
pharmacists on National TB
management guidelines and PP
coordination
Train private providers and
pharmacists on national TB
management guidelines, and to initiate
and refill TB treatment regimens
Strategy 2.3
$230,000
$200,000
$210,000
$640,000
Engage alternative health
practitioners TB screening and referral
for diagnosis and management
Above allocation
Pilot accreditation of a sub-set of
private pharmacies for TB treatment
initiation
Govt: %
Strategy 2.4
$420,000
$410,000
$440,000
$1,270,000
GF: %
No prioritized activities
Other: 0%
Objective 3 To implement and expand country-wide collaborative TB/HIV activities
and management of co-morbidities by 2019
Strategic intervention 3.1
The government has committed full funding for the National TB/HIV coordinator and the
four regional TB/HIV coordinators, pending absorption into the government
establishment. The National Coordinating Committee -TB/HIV (NCC) exists and the
membership constitutes of Developmental partners, TB and HIV stakeholders. The meeting
are held on quarterly basis and is co-chaired by TB and HIV program managers. The main
objective of the NCC-TB/HIV is to provide guidance and strategic direction on TB/HIV
collaborative activities and development of policies. The NCC-TB/HIV is replicated at the
regional levels and is complemented by Multidisciplinary teams at service delivery
levels/facilities.
Funding support from the GF will enable strengthening of existing NCC structures at
service delivery level. This will include conducting quarterly joint TB/HIV national and
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 51
regional planning meetings to facilitate optimal work flow assessment, TB/HIV training
PSM issues and CSS.
Strategic intervention 3.2
The government through support from the World Bank has developed national and regional
structures for TB infection, prevention and Control (TB IPC). The IPC team ensure
implementation and compliance to the TB IPC guidelines as well development of facility
structures with regards to IPC e.g. establishing IPC committees. The government funds the
salaries of the IPC focal person within the facilities as well as procurement of some of
personal protective equipment (PPE).GF also supported PPE implementation to ensure no
stock outs at facility level.
Cost sharing of Rural health motivators (RHMs) salaries is supported by both GF and
government while community TB treatment supporters are fully GF supported including
IPC trainings thereof. Cough officers are stationed at entry points in most of the health
facilities including HIV care setting to provide intensified case finding. This cadre, which
facilitate early diagnosis and prompt treatment initiation, is supported by GF and
government through the World Bank loan. The Swaziland government has committed to
full funding of Isoniazid Preventive Therapy (IPT) implementation which is currently being
rolled out in a stepwise approach to reduce the burden of TB in PLHIV.
Above allocation
Funding requested from GF will facilitate implementation of environmental control
measures to address issues of non IPC compliance in lower levels BMUs. This includes the
procurement of additional prefabs to limit nosocomial TB transmission.
Strategic intervention 3.3
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. This also includes the
integration of HIV services for TB/HIV co-infected patients which has facilitated the scale
up of a “one stop shop” model thereby reducing opportunity cost for patients as follow up
appointment are synchronized.
The funding from GF will sustain further scale up for the provision of ART which will be
cost shared with the government under the Swaziland National AIDS program ( SNAP).
Strategic intervention 3.4
The government has committed to continue funding HR, HCWs trainings, provision of
dialysis services and uninterrupted supply of diagnostics commodities in support of
Intensive case finding amongst patients with co-morbidities e.g. diabetic patients.
Strategic intervention 3.5
Government’s commitment to the ongoing decentralization of TB services to lower level
clinics includes salaries of facility staff, infrastructure refurbishment, and provision of free
TB treatment as well as pre service trainings for registered nurses. The government has also
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 52
developed a referral system enhance continuity of care from community level to the various
level of the health care system.
Table 8 Funding request for priority strategic interventions under objective 3
OBJ 3
Strategy 3.1
2015
2016
2017
$1.20
$1.20
$1.30
$0.17
$0.14
$0.15
TOTAL
% Funding
GF Supported Interventions
$3.60
Within allocation
$0.46
Establish a coordinating body for
collaborative activities functional at
all levels
Within allocation
Strategy 3.2
$0.74
Strengthen implementation of PPE in
health care facilities
$0.76
$0.80
$2.30
Above allocation
Strengthen implementation of
environmental control measures in
health care facilities and
communities.
Strategy 3.3
Strategy 3.4
Strategy 3.5
$0.00
$0.30
$0.03
$0.00
$0.32
$0.02
$0.00
$0.34
$0.02
$0.00
$0.96
$0.07
Activities under this strategic
intervention is budgeted for by the
HIV program
No interventions are prioritized to be
supported by GF
No interventions are prioritized to be
supported by GF
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.
Strategy 4.1: Preventing the development and transmission of drug resistant TB strains
The NTCP will review and develop IPC checklist specific for DR-TB sites. Structural
adjustments will be done in DR TB facilities such as installation of mechanical ventilation.
Furthermore the national DS -TB training curriculum will be reviewed to focus on early
diagnosis and appropriate management of DR-TB. Funding support from Global fund will
enable the program to conduct media and community campaigns to increase community
awareness of DR-TB screening, diagnosis and management. Government will continue to
support the two national MDR-TB coordinators and the NTCP MDR –TB focal person.
Strategy 4.2 Strengthen case finding for MDR-TB among high risk populations (i.e. health
care workers, mine workers, inmates, and industrial workers)
Healthcare workers and public health managers will be trained on intensified case finding,
early identification and appropriate clinical and programmatic management of MDR-TB
suspects and special attention will be given to high risk populations (health care workers,
mine workers, prisoners and children). Global Fund has been supporting the salaries of the
regional MDR-TB clinical teams (Two Doctors and three Nurses in each team) who conduct
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 53
home assessment, GIS mapping and contact investigation as part of their community
outreach activities. Funding support will be requested from Global Fund for continuation
of these activities.
For this activity the programme through Global Fund will purchase ambulances to facilitate
DR-TB patients’ transportation as these patients are currently using public transportation
as the country’s ambulances are not suitable for transportation of DR-TB patients, thereby
contributing to community transmission of DR-TB. Government’s contribution to patient
transportation is support of salaries for emergency medical services (EMS) personnel and
a 24 hour emergency medical call centre (toll free number).
Strategy 4.3: Increase access to MDR-TB treatment initiation
Currently there is an MDR- TB outreach clinical team in each region who provide support
and mentorship to facility HCW on MDR-TB diagnosis and management. With further
Global Fund support, the NTCP aims to decentralize DR-TB treatment services to 5
additional heath care facilities bringing the total number of DR-TB treatment initiation
sites to 13 by 2019. This includes intensive training and supportive supervision of health
care workers on DR-TB clinical management. As the decentralization process is ongoing,
facility staff salaries are fully supported by the government.
Strategy 4.4: Ensure timely enrolment of all bacteriologically diagnosed DR-TB patients
on treatment
The pprogrammatic management of DR-TB (PMDT) according to WHO guidelines has
already been introduced in DR-TB treatment initiating facilities. As of 2011 Swaziland
adopted GeneXpert MTB/RIF as the initial diagnostic test for all presumptive TB cases
thereby facilitating prompt identification of drug resistant TB. The Swaziland government,
since inception of NTCP, has committed to provide free first and second line drug therapy
to all diagnosed TB patients. To facilitate timely enrolment of patients on treatment, the
NTCP in collaboration with technical partners has committed to conducting operational
research evaluating systematic leakages in the diagnostic pathway of DR-TB patients. This
includes strengthening of the laboratory information system (LIS) to enable real-time
surveillance and notification of diagnosed patients to the NTCP and MDR-TB facilities. A
surveillance system for GIS mapping of DR-TB patients has been developed in collaboration
with technical partners to facilitate patient follow up and monitoring.
Strategy 4.5: strengthen case management (inpatient and ambulatory)
Under strengthening of case management, Global Fund will support the NTCP to purchase
audiology equipment’s and train health care workers on audio screening to facilitate the
scale up of audiology services to all DR-TB treatment initiating sites. The government of
Swaziland has committed to funding of the Audiologist based at the TB hospital for
centralized case management, while funding will be requested from GF for an additional
Audiologist to provide decentralized case management at the regional level. Part of
government’s commitment to TB control activities has been the provision of free TB
services (DS and DR-TB), including inpatient care.
Strategy 4.6: Strengthen community DR-TB management, care and support
Community DR-TB management, care and support will be strengthened by ensuring a
discharge plan is in place to enable continuous care and support for DR-TB patients at
community level. A team consisting of a family treatment supporter, community treatment
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 54
supporter, expert client and health care workers provide care and support to the patient
once discharged from DR –TB facilities. Funding support from Global fund will enable the
recruitment and training of additional treatment supporters as informed by the number of
patients (each patient will be supported by a community treatment supporter tasked with
DOT and to accompany the patient to a health facility for every follow up appointment).
4.7 Establish a Palliative Care and support package for DR-TB Patients
The NTCP will implement services which will contribute to the improvement of the quality
of life among DR-TB patients. Palliative care coordinators- representatives from SNAP and
NTCP will develop guidelines on Providing Palliative Care to Patients with DR-TB which
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 and are fully
government supported employees.
4.8: Improve gender equity/ sensitivity in DR-TB care and management
To address gender specific challenges in MDR-TB care and management, correlates of
gender will be analysed in order to inform the, development and dissemination of genderspecific information on MDR-TB care and management. This will be conducted in
collaboration with developmental partners and funding assistance will be requested from
the GF.
4.9: Advocate for supportive public health policies and legislations
An Occupational Health care package for health workers will be developed to ensure that
all health care workers are protected, supported and compensated accordingly should they
contract TB whilst performing their duties. Technical assistant from partners will support
the development of a legal framework.
Table 9 Funding request for priority strategic interventions under objective 4
2015
2016
2017
TOTAL
OBJ 4
$11,070,0
00
$11,800,0
00
$12,100,0
00
$34,970,00
0
Strategy
4.1
$290,000
$310,000
$350,000
$950,000
Strategy
4.2
%
Funding
Govt: %
GF: %
Other:
0%
Govt: %
GF: %
Other: 0%
$1,040,000
$490,000
$910,000
$2,440,00
0
GF Supported priority
activities
Enhance early recognition of
DR TB among the drug
susceptible TB patients
Govt: %
Ambulances - 1 per region for
MDR-TB patient transport
GF: %
Conduct microscopy and first
line DST/culture tests for DR
TB patient monitoring and
follow up
Other: 0%
Govt: %
Strategy
4.3
$2,150,000
Strategy
4.4
$20,000
Strategy
4.5
$7,110,000
Strategy
4.6
$590,000
$1,430,000
$1,550,000
$5,130,000
GF: %
Other: 0%
Govt: %
$20,000
$20,000
$60,000
GF: %
Other: 0%
Govt: %
$7,530,000
$7,980,000
$5,190,000
GF: %
Other: 0%
$610,000
TB and HIV Concept Note Swaziland Draft III
$640,000
$1,840,000
Govt: %
GF: %
Decentralize DR TB
treatment initiating to at least
5 more healthcare facilities
No priority activities to be
supported by GF
Scale up of audiology services
to all DR-TB treatment
initiating sites
Ensure all DR-TB patients
enrolled on treatment have a
03 Oct 2014│ 55
Other: 0%
Strategy
4.7
Govt: %
$450,000
$480,000
$510,000
$1,440,000
GF: %
Other: 0%
Govt: %
Strategy
4.8
$80,000
Strategy
4.9
$30,000
$80,000
$90,000
3,280,000
GF: %
Other: 0%
Govt: %
$60,000
$30,000
$120,000
GF: %
Other: 0%
community and family
treatment supporter
No priority activities to be
supported by GF
No priority activities to be
supported by GF
No priority activities to be
supported by GF
Objective 5: To strengthen the NTCP national TB response management capacity to
effectively coordinate and evaluate TB prevention, treatment and care interventions.
5.1: Strengthen program management and coordination:
The Government has committed to permanent salary support of the NTCP Manager and
thematic leads (National DOTS coordinator, National TB/HIV coordinator, National MDRTB coordinators (2), National Paediatric TB coordinator). Recent government commitment
includes absorption into the government establishment of the following positions: Research
Monitoring and Evaluation officer, four Regional TB/HIV coordinators and four Data
clerks and funding assistance will be requested from GF to support key HR critical for
successful program implementation.
To assess the epidemiological status of TB and HIV in the country as well as the
implementation of the TB NSP (2015 – 2019), it’s vital to conduct a mid-term review in
2017 for which funding support will be requested from the GF, including for annual
programmatic review/work plan development meetings.
Above allocation
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
international/regional meetings, which facilitate sharing of best practices in TB Control
between TB programs and Technical experts.
5.2 Health Systems Strengthening
The incoming NSP 2015-2019 has incorporated the various components of HSS in the
development of each objective.
5.3 Monitoring and Evaluation (M&E)
For successful implementation of the M&E framework, maintenance of quality assurance
and quality improvement is critical and to this end, the NTCP conducts monthly multidisciplinary supervision visits to facilities in teams consisting of the M&E officer, National
TB/HIV Coordinators, NTRL Manager, National DOTS Coordinator, National IPC
Coordinator and National MDR-TB Coordinators. Global fund will be requested to
continue ongoing support of training and supportive supervision of community and facility
health care workers, conduct of quarterly/semi-annual review meeting as well as printing
of recording and reporting tools.
5.4 Surveillance and Research
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 56
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.
Funding assistance will be requested from GF to conduct a paediatric inventory study.
Table 10 Funding request for priority strategic interventions under objective 5
OBJ 5
Strategy
5.1
2015
2016
2017
$8.10
$6.30
$7.80
$5.00
$5.36
$6.75
TOTA
L
$22.2
0
% Funding
$17.11
Activities
Within allocation
-NTCP staff salaries
-Conduct joint MID-TERM review of NTCP
and SNAP.
-NTCP administration
- Annual Program review meeting/ Annual
work plan development meetings
Above allocation
Capacity strengthening of PMDT and M&E
Strategy
5.2
$0.08
$0.07
$0.09
$0.24
Diseases specific HSS activities are
included in other objectives
Within allocation
Strategy
5.3
$0.75
$0.71
$0.76
$2.22
-Conduct trainings of HCWs to improve TB
data recording and reporting
-Printing of M&E recording and reporting
tools
-Conduct Quarterly/Semi-annual review
meetings
Within allocation
Strategy
5.4
$2.29
$0.00
$0.00
$2.29
-Conduct Inventory studies to assess the
level of under-reporting of childhood TB
-Conduct TB prevalence survey
-Conduct Drug-Resistance Survey
3.2.3. Health Systems Strengthening
Objectives
(i) To implement the Computerised Client Management Information System (CMIS),
provide infrastructure and equipment To link the different sources of Information,
and build capacity for analysis and use of health Information
(ii) To rollout service delivery systems across the country - specifically closing gaps in
supervision systems, outreach services provision, referral services, and
infrastructure and equipment needed to organize and manage the provision of care.
(iii)To improve the health products procurement and supply chain management
systems, and monitoring of rational use of health products in the country
(iv) To build capacity of human resources for health with a focus on supply chain
management, community health services and health information systems
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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 57
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 3.44M 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 11).
Table 11: Funding Request Details for HMIS
LAN
WAN
Hardware/
Peripherals
Original
“hybrid” model
Local Area Network
(LAN) connection to
facility
Two network
connections per site
Evolved
“real-time” model
Same
- 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)
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
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 understocking 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
analyze 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 58
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.
Refurbishment and Operationalization of Integrated WarehouseGovernment 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 following support;
-
Refurbishment of warehouse
Shelving of warehouse
Purchase of operational equipment i.e. Fork lifters, Trolleys, Pallet jack, pallets
Purchase of furniture and Air conditioners
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 Landcruiser panel vans will be used to deliver supplies to all facilities even those that are in
remote areas.
Implementation of Bar Code Scanners-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 T.B. The specific request is for; Computers, Purchase of Bar Code
Scanners and Printers, Training, and Software.
iii)
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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 59
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.
iv)
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)
b. Train health admin on health systems mgt (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
a. Conduct orientation for newly appointed and promoted health officials, ,
b. Implement the renewed primary healthcare strategy for Africa,
c. Orient critical ministries on the social determinants of health with emphasis on
HIV/AIDS, TB, Malaria and NCDs (5 key ministries)
Table 12 Funding request for priority Health Systems Strengthening (HSS)
2015
2016
2017
TOTAL
$2,621,129
$2,884,331
$1,992,810
$7,498,270
$642,987
$400,562
$406,157
$1,449,705
812,549
1,302,375
1,127,095
3,242,020
145,462
27,221
28,355
201,038
$1,232,561
$1,029,846
$280,654
2,543,061
466,595
479,475
479,475
1,425,544
299,001
299,001
299,001
897,003
Allocation
$109,424.31
$72,634.69
$105,586.16
$ 287,645
Above
$198,523.67
$74,340.26
$78,800.68
$351,664
Allocation
Total Funding Request
Above
Allocation
Module
Health Information
Systems and M&E
Procurement and
Supply Chain
Management
Above
Allocation
Allocation
Service Delivery
Health and Community
Workforce
TB and HIV Concept Note Swaziland Draft III
Above
03 Oct 2014│ 60
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 organizations,
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 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.
Strategic interventions
i)
Community based monitoring for accountability: the activities include baseline
assessment on gaps and needs, developing a service directory, a data base,
incentives for planning and reviews, monitoring, documentation and reporting.
Other activities will include harmonizing tools and establishing linkages in data
management. Promotion and sensitization on principles of right-based program
planning including developing indicators to track progress, and disseminate data
for use. 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 in program monitoring.
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 will play a role
in monitoring of the services including ensuring the selection of volunteers and
participating in planning program intervention.
ii)
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 opportunities for vulnerable women and girls will be implemented (small
business, saving, credit). Additionally, gender score assessment and 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 61
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 to improve the skills of existing officers and support
communities to expand the reach of the program. It will also contribute to promote
gender equity through the above illustrated activities.
iii)
Institutional capacity building in planning and leadership development for civil
society organizations implementing TB, HIV and malaria services: Institutional
capacity building activities include training of community based organizations on
project development and management; organizational development, and finance
and grant management. In addition, community health workers will be trained
using the standardized training curriculum to provide integrated services.
Currently, PSI supports support 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 funding from the GF will support the above activities so that there is a functional
institutional capacity at the community level.
Table 13 Funding request for priority CSS interventions
CSS MODULES
Total Funding Request
1)
Community based
monitoring for
accountability
2)
Social mobilization,
building community
linkages, collaboration
and coordination
3)
Institutional capacity
building planning and
leadership development
in the community sector
TB and HIV Concept Note Swaziland Draft III
2015
2016
2017
Total
Allocation
687,171.59
526,371.90
453,479.41
1,667,022.90
Allocation
535,016.49
83,929.43
83,843.86
702,789.78
Allocation
152,155.10
341,158.24
254,157.05
747,470.39
Above
687,767.08
827,403.50
878,175.92
1,905,346.50
Allocation
-
101,284.23
115,478.50
216,762.73
03 Oct 2014│ 62
3.3 Modular Template
Complete the modular template (Table3).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.
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 63
HIV Program
Prevention Module
Rationale for interventions:
In view if the fact that heterosexual transmission is the main mode of HIV spread, the eNSF
prioritizes prevention of sexual transmission as key to reverse the trend. It also gives due
emphasis for PMTCT. Accordingly, interventions that are targeting populations at highest
risk of HIV infection such as women and girls, key populations and men are given due
attention in the concept note. All prevention activities included in the modules respond
directly to the challenges in the prevention response, they also currently have a gap in
funding and fall within priority areas in the eNSF.
1) SBC: to scale up targeted interventions focusing on young women and men in and out of
school. An emphasis will be on young girls. The rationale for focusing on this target
group is that they have the highest HIV incidence; risky behaviors such as low condom
use, intergenerational sex and early sexual debut including high risk of gender based
violence particularly sexual violence.
This request will support capacity building of existing community structures on mobilization
of communities for increased uptake of HIV services and promotion of safe sexual behaviors.
Activities under this area align to the following priority strategies in the eNSF for SBC;
Strategy III: Intensify social and behavior change interventions tailored to specific target
groups as guided by evidence, with intensity and coverage for impact at population level
Strategy IV: Intensify community mobilization and community referral systems for
service uptake
Expected outcomes:
 Increased personal risk perception among targeted populations (including males)
 Accelerated demand and uptake for prevention services
 Reduction risky sexual behaviors
 Strengthened community capacity for mobilization for HIV
2) 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 to drive demand for MC. Over the next five years
PEPFAR will support to scale up provision of clinical services and localized demand
creation through outreach, mobile, and some integrated service points. The request to
the Global Fund is for targeted MC promotion in male dominated forums such as
community-based soccer games, MC education and promotion. The request also
includes support for mobile clinics to support community outreach. Activities under this
area align to the following priority strategies in the eNSF for MC;
 Strategy I: Strengthen and decentralize MC services especially for neonates and
males (10-35) in health and non-health facilities
 Strategy II Intensify education, awareness and community mobilization to
generate demand and increased benefits of MC for both men and women
Expected outcomes from activities under this area;

Increase the number of males circumcised
3) Key Populations: sex workers, men who have sex with other men (MSM), prisoners and
mobile populations are identified as populations at higher risk of HIV infection, with limited
customized targeted programs. Further HIV prevalence among key populations is high and
levels of HIV risk perception is low. PEPFAR and the Government provide services reaching
SWs and MSM through mobile outreach, promotion and distribution of condoms and
lubricants. In the next 5 years PEPFAR will provide funding for sensitization and training of
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 64
law enforcement officers as well as the population size estimate study. UNODC continues to
support HIV interventions targeting inmates and prison officials. The training of healthcare
workers and peer educators among FSW, MSM and transport operators remains a gap.
Global Fund support is requested for the training of healthcare workers to provide nondiscriminatory services and peer educators focused on peer-to peer risk reduction. Activities
under this area align to the following priority strategies in the eNSF for key populations;
Strategy I: Develop and implement community and institutional based strategies that
address gender, stigma and discrimination
Strategy III: Develop and implement customized strategic interventions targeting key
population
Expected outcomes from activities under this area;


Increase the number of SW, MSM and Transport operators reporting access to HIV
services including condoms
Increase the proportion of key population with comprehensive knowledge on HIV
4) PMTCT: The national PMTCT program data shows that only 2% of children born to HIV
positive mothers are infected with HIV at ages 6-8 weeks. This is a promising trend
towards the elimination of MTCT. 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 11% post 8 weeks. The unmet need
for Family planning among HIV positive women is 65% whilst in the general population
it is currently 13%. The national SRH program has introduced more efficacious longterm family planning methods, however, there is a need to build the capacity ofhealth
care workers to insert devices, improve quality of care and promote long-term FP.
UNFPA and the Swazi Government are supporting procurement of all FP commodities;
however, capacity building for health care workers remains a gap.
The request to the Global Fund is to scale up provision of care and support to HIV
positive mothers through mentor mother and expert clients; and for training of
healthcare. Activities under this area align to the following priority strategies in the eNSF
for PMTCT;
Strategy II: Intensify the prevention of unintended pregnancies among HIV positive
women
Strategy IV: Intensify provision of treatment care and support to mother living with HIV,
their children and families
Expected outcomes from activities under this area;


Increase access and uptake of family planning methods among women living with
HIV
Increase retention and adherence to lifelong ART among HIV+ pregnant and
lactating
5) Condoms: National condom coverage is relatively low at 41.7%, as such 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.
The Government will refurbish the warehouse to improve storage at CMS and service
delivery points. UNFPA has committed to procuring 10million condoms annually; PEPFAR
will also procure approximately 4 million specialty condoms and has allocated a budget of
USD1.5 million for distribution and promotion of condoms for youth and key populations.
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 65
AIDS Health Care Foundation (AHF) has also committed to procuring 4.4million condoms
annually over the next 3 years.
The request to the Global Fund for the procurement of 10million condoms has been put in
the allocation due to the uncertainties of the funding landscape.Procurement of vending
machine for placement in hot spots and training of community health care works on
promotion distribution and reporting. Activities under this area align to the following
priority strategies in the eNSF for Condoms;
Strategy II: Intensify access, demand creation and distribution of condoms using multiple
approaches including integration in other health care services and
Strategy III: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
Expected outcomes from activities under this area;
 More young people aged 15-24 use condoms at first sex
 Increased access and distribution of condoms
6) 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 to drive demand for MC and accelerate reaching set targets. Over the next five
years PEPFAR will support the MOH efforts to scale up provision of clinical services and
localized demand creation through outreach, mobile, and some integrated service points.
However transportation for the successful Back-to-school campaigns and MC Fridays is
remains a gap. The request to the Global Fund is aimed at intensifying targeted MC
promotion in male dominated forums such as community-based soccer games, using
innovative approached to reach targeted populations with MC education and promotion.
The request also includes support for mobile clinics to support community outreach.
Activities under this area align to the following priority strategies in the eNSF for MC;


Strategy I: Strengthen and decentralize MC services especially for neonates and
males (10-35) in health and non-health facilities
Strategy II Intensify education, awareness and community mobilization to
generate demand and increased benefits of MC for both men and women
Expected outcomes from activities under this area;

Increase the number of males circumcised
7) GBV: Gender Based Violence including sexual abuse remains a challenge and according
to the ‘National Study on Violence against Children and Young Women in Swaziland’
(2007), 1 in 4 young females has experienced physical violence as a child and 5% have
been forced to have sex before the age of 18.
The country has established a One-Stop Centre in the Hhohho region through Government,
UNICEF and PEPFAR support and in the process of establishing 3 additional centres in the
remaining regions. The MoH in collaboration with partners has developed GBV guidelines
and training manuals to improve capacity and enhance harmonization of service delivery. A
pool of trainers will be established in country to continue with decentralized training of
health care workers in line with the GBV guidelines. However, the availability trained
forensic nurses and community awareness on GBV remains a gap. Funding from the Global
Fund is being requested to train forensic nurses, community sensitization and training of
community protectors on GBV prevention and response. Activities under this area align to
the following priority strategies in the eNSF for GBV
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Strategy 5 Intensify the provision of comprehensive health services for the management of
GBV casesStrategy III: Develop and implement customized strategic interventions
targeting key population
Expected outcomes from activities under this area;


Increase community awareness on GBV prevention and service availability
Increase capacity of health care workers, communities and duty bearers to respond
to GBV
Antiretroviral Therapy Module
Rationale
The strategies and activities where prioritized based on the gaps identified in the situational
analysis. Priority activities were selected based on programmatic gaps identified during the
Joint review of the National Strategic Framework 2009 – 2014 and the funding gaps based
on the financial gap analysis. This was followed by a prioritization process to select high
impact strategies and interventions that are targeted, sustainable and where the health
system has the capacity to absorb the deliver the service and absorb the funds. The identified
strategic priorities and activities are also in line with the NHSSP II regarding universal
access services and improving patient outcomes
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 80% of all public facilities. ART scale up though will strain
service delivery at these facilities despite the widespread decentralization of services. Hence
the deliberate move to shift 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 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 a) 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 start of ART program.
The major outcome of this intervention is that at least 80% of PLHIV will be on ART by
2018. This will be achieved by putting about 90% of people in need of ART based on current
WHO recommendations. Patients with CD4 less 350cells/mm3 will be a priority and the
target is 95% coverage in this population.
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. 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. 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 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 67
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.
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.
Nutritional Support: Approximately 11% of patients initiating ART in Swaziland are
malnourished (based on BMI and MUAC measurements). An additional 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 (national support) 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.
Funding above allocation
In the above allocation request ($5,389,742) is for support in the procurement of
hematology and chemistry reagents to cope with scale up of ART provision. This is critical
in ensuring that quality of service delivery is maintained. Current first line regimens used
are TDF and AZT based and the possibility of toxicity (anemia 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 affect both adherence and overall retention in care.
------------------------------------------------------------------------------------------------------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:
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.
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 68
Rationale for selection and prioritization of Modules and Interventions:
The selection of modules and 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 (2010-2014) and consultation process with all stakeholders in the country.
Modules prioritized in this request 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 enroll 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 achievements 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. In addition, the country has not in the recent past conducted
a TB prevalence survey,
The possibility of cost-sharing of this activity with assistance from the Swaziland
Government and Technical Partners will be explored, particularly as an understanding of
the level and trends in disease burden will ensure the appropriate allocation of funding to
save more lives in the future.
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 is
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 DS-TB and DR-TB patients with
electronic monitoring of these patients. The funding request includes procurement of
additional Garmin tracking devices as more patients are diagnosed. Additional Cough
Officers will be recruited, trained and stationed at all main entry points within health
facilities to facilitate the expansion of systematic screening and the implementation of
Infection Prevention and Control (IPC) measures at the facility level.
A mobile TB clinic will be procured to provide TB screening, onsite diagnosis and treatment
initiation of key populations in congregate settings and under-served, hard to reach areas as
well as TB hot-spots. The mobile clinic will also be used to provide services during
community campaigns and social mobilization activities aimed at increasing TB awareness
in communities and create demand for contact investigation.
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 Organizations 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
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 69
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. Therefore, the ongoing decentralization of TB laboratories through the
upgrade of mini-laboratories is critical to support TB diagnostic services in the country. The
NFM funding request will procure an additional 15 GeneXpert machines 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 and Xpert cartridges will also be included in the NFM to ensure an
uninterrupted supply of critical laboratory supplies and commodities.
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 have
undergone 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. 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 04yrs (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 TB interventions in the NFM concept note.
The country intends to increase detection of TB among children by integrating TB screening
at ANC and MCH clinics. This includes engagement with other child care 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-centered 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. The Round 10 grant has also provided
critical support of Community Treatment supporters and Adherence Officers. The
Adherence Officers provide defaulter tracing services in collaboration with facility staff and
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 70
community Treatment Supporters. 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 they will work closely with regional coordinators, who will supervise
and monitor successful implementation of TB services in facilities and communities. TB
control services will be implemented as follows (from the lowest level to high level); The
program request support for Community service coordinator to strengthen the community
health care interventions particularly integrated trainings and monitoring of community
based activities.
Community level
RHMs (5300) and Community Treatment supporters will be assigned to a certain number
of homesteads within the clinic catchment area to conduct contact tracing and active case
finding activities. To support these activities, they will be trained on TB case detection and
management as they will screen all household members within assigned homesteads, refer
those who screen positive for TB to the nearest clinic for further assessment and provide
DOT support to diagnosed TB patients. These cadre submit monthly report to the health
facility.
Clinic level
Cough officers: The Cough officers will screen all patients at all entry points in health
facilities to conduct intensified case finding. Cough officers will report to the health facilities
and they will be supervised by the nurses and will work together with the Adherence officers
who are based at hospitals/ health centers. Once the cough officer receive diagnostic test
results will then liaise with the adherence officer to contact the patient for commencement
of treatment.
Hospitals and health centres
Adherence officers act as a linkage between hospitals/health centers and satellite clinics
within the catchment area. They will transport samples from the community clinics to the
hospitals/health centres. Defaulter tracing by the adherence officers occurs from two
angles:1. Facility staff will notify them of patients who has defaulted treatment. 2. The
Community treatment supporters will alert the Adherence officers of patients, who have
defaulted treatment. Adherence officers will provide progress report for hospital/ health
Centre (including clinics).
TB 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. 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 (Treatment supporters,
Adherence Officers, Cough Officers, RHMs etc.) as well as conducting monthly supportive
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 71
supervision with thematic leads (National M&E officer, National TB/HIV Coordinators,
NTRL Manager, National DOTS Coordinator, National IPC Coordinator and National MDRTB Coordinators to ensure maintenance of quality assurance and improvement of patient
care.).Accurate and valid data increases credibility of data The program through the M&E
will conduct Data verification. The funding request includes support for M&E capacity
building and the purchase of a vehicle for use by the M&E team to enable weekly on-site
mentoring visits and the above mentioned activities.
Data quality improvement and assurance is critical to make evidence base decision making.
The program will conduct National and Regional Quarterly Review meetings enhance
understanding TB data, without which a program cannot evaluate its performance to inform
evidence-based decision-making. 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 mid-term external
program review will be conducted in 2017.
Disease surveillance is critical for successful management of programs and funding is
requested to develop a surveillance model and manual. This system and ETR are different
from the CMIS, as the latter cannot accommodate necessary TB data variables required for
patient monitoring and ongoing statistical analysis.
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 includes a Clinician Researcher to
develop and coordinate critical research activities for example the DRS and Prevalence
survey. This is also in line with the NSP 2015-2019 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 indicative 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 organization.
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-indicative funding are those considered
as potentially high impact in the context of Swaziland and by no means less prioritized. The
TB and HIV Concept Note Swaziland Draft III
03 Oct 2014│ 72
selected activities are priority towards improving TB case notification and treatment success
rate.
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.
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. .
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 currently being decentralized to regions with plans to
further decentralize to lower level facilities. This is critical as in waziland, 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.
Allocated funding
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.
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.
3. MDR-TB module
Diagnostic capacity for case detection of drug resistant TB remains limited, despite on-going
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.
Allocated funding
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 decisionmaking on DR-TB surveillance.
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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 as well the procurement of ambulances to be used specifically for transportation
of MDR-TB patients who are currently using public transportation to access medical
services. This is due to the limited resources of the Emergency Preparedness Response
(EPR) unit who are currently unable to transport TB and MDR-TB patients due to IPC
challenges. The funding request is to procure one ambulance per region which will be
stationed at the EPR unit in that region. The ambulances will be operating within the health
facilities that admit MDR-TB patients which are currently two per region.
The national capacity for R-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 of DR-TB Treatment initiating sites to an additional 5 facilities to meet the
target of 13 DR-TB sites by 2019 will be supported while strengthening 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 ensure
accessibility to services and also alleviate opportunity costs for patients.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. This is an intervention 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 which
are both inadequately covered by the MDR-TB care services.
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 an Audiologist, install audiology
equipment in DR-TB sites, train healthcare workers on Audio-screening and provide
hearing aids for affected patients. Funding support for treatment supporters is expected to
improve DR-TB treatment outcomes.
The funding will also support annual GLC technical support visits to strengthen PMDT
capacity.
Above allocated funding request
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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.
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.
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 currently consisting
three separate supply chains (medicines, ARV and laboratory).
Allocated funding
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
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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.
Allocated amount
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
behavior 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 wellpositioned to develop and retain positions critical to the delivery of quality health services.
Allocated Funding
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 Allocated Funding
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 organizations 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.
Swaziland is classified as a lower-middle income country by the World Bank. 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 behavior change, economic empowerment, etc).
Likewise, activities under PMTCT serve women and children-who both are among
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 which 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.
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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 organizations, 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
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
Prevention- mother to Child transmission
Summary of Implementation Arrangements for Government PR
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
organizations 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, ddescribe 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
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activities.
Continuation of critical TB control activities funded under the current grant and the no-cost
extension plan have been prioritized in the NFM. These activities will allow the NTCP 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
GOV
☐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,
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excluding the Transitional Funding Mechanism for
AIDS, is as follows:
Round
Disease
Component
Overall
Performance
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 subrecipient 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 Organizations (CSO)
predominantly working in the area of HIV/ AIDS,
irrespective of whether they are recipients or nonrecipients 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,
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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.
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 distributionsystems and
transportation arrangements
are
efficient
to
ensure
The procurement system of NERCHA is robust and
complies with the procurement requirements of the
Global Fund in all respects. This was developed
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continued and secured supply
of health products to end users
to avoid treatment / program
disruptions
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
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
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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
Organizations
[CANGO]
Does this Principal Recipient
currently manage a Global
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
Civil Society
[NGOs]
Sector
Yes
X No
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 subrecipients (and relevant
sub-sub-recipients)
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.
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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 [MEROCAT], Programs and Technical capacity assessment
tool [PT-OCAT] 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
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
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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.
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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
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
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
TB and HIV Concept Note Swaziland Draft III
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.
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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.
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
raising 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.
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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.
iii.
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.
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
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03 Oct 2014│ 89
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 Organizations 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.
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
organizations which are SRs. This relates to risks whose mitigation requires the
support of other Government Ministries or and civil society organizations 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).
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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.
☐
Table1: Financial Gap Analysis and Counterpart FinancingTable
☐
Table2: Programmatic Gap Table(s)
☐
Table3: Modular Template
☐
Table4: List of Abbreviations and Attachments
☐
CCM Eligibility Requirements
☐
CCM Endorsement of Concept Note
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Sources:
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